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R  A776  .C85  How  to  keep  well;  an 


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KEEP 
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FLOYD  M. 

CRANDALL 


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COLLEGE  OF  PHYSICIANS 
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HOW  TO   KEEP  WELL 


HOW  TO  KEEP  WELL 


AN     EXPLANATION     OF     MODERN 

METHODS  OF  PREVENTING 

DISEASE 


BY 


FLOYD  M.  CRANDALL,  M.  D. 


NEW  YORK 

DOUBLEDAY,  PAGE   &  COMPANY 

1903 


Copyright,  190?,  by 
Doubleday,  Page  &  Company 

Published,  May,  igoj 


tto  ^v  ^ot^tt 


CONTENTS 


Introduction 


CHAPTER 


I.  Modern  Medicine 
II.  The  Causes  of  Disease 

III.  Bacteria 

IV.  Infections     and     Contagions — Their 

Management  and  Control 
V.  The  Infectious  Diseases     . 
VI.  Antitoxins 
VII.  Vaccination 
VIII.  The    Effect    of    Modern    Life    upon 
Disease 
IX,  The   Rearing  of  Children 
X.  The  Diet  of  Children 
XI.  Faulty    Nutrition    of    Children 
XII.  Heredity 

XIII.  Regimen  of  Adult  Life      . 

XIV.  The  Dangers  of  Middle  Life 
XV.  The  Prevention  of  Breakdown 

XVL   Diseases  Common  to  Middle  Life. 
XVII.  The  Sedentary  Life  . 
XVIII.   Age  and  Its  Advancement 
XIX.  Modern  Surgery 


PAGE 
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403 

451 
469 

484 


vu 


"  We  live  in  a  small  bright  oasis  of  knowledge  surrounded  on  all 
sides  by  a  vast  unexplored  region  of  impregnable  mystery.  From 
age  to  age  the  strenuous  labour  of  successive  generations  wins  a 
small  strip  from  the  desert  and  pushes  forward  the  boundaries  of 
knowledge." — Lord  Salisbury. 


"  Search  the  scriptures  of  human  achievement  and  you  cannot 
parallel  in  beneficence,  Anesthesia,  Sanitation  with  all  that  it  in- 
cludes, and  Asepsis — a  short  half  century's  contribution  toward  the 
practical  solution  of  the  problems  of  human  suffering,  before  re- 
garded as  eternal  and  insoluble." — Doctor  Osier. 


INTRODUCTION 

How  medicine  has  arisen  from  mysticism, 
supernaturalism,  and  superstition,  and,  having 
gradually  emerged  from  the  thraldom  of  astrology 
upon  the  one  hand  and  theology  upon  the  other, 
now  stands  forth  in  the  foremost  rank  of  the 
sciences — 

Why  it  is  worthy  of  acceptance  rather  than  the 
crude  systems  of  quackery  and  pseudo-science 
which  one  after  another  arise  only  to  sink  into 
obscurity — 

To  set  forth  our  knowledge  regarding  the  pre- 
vention of  disease  and  to  show  what  advances  have 
been  made  in  recent  years  in  our  ability  to  prolong 
life  and  to  prevent  suffering,  disease  and  death — 

These  things  I  have  endeavoured  to  tell  in 
language  that  all  can  understand  and  may  thus 
profit  by  the  knowledge  accumulated  during  long 
years  of  patient  toil  by  medical  workers  in  the 
laboratory,  the  post-mortem  room,  and  the 
hospital. 

In  very  ancient  times,  medical  practice  was  in 
the  hands  of  the  priesthood,  and  medical  science 

xi 


[1^ 


xii  INTRODUCTION 

was  closely  interwoven  with  mythology.  Having 
partially  thrown  off  the  shackles  of  such  slavery, 
it  began  to  develop  a  true  science.  But  as  the  Dark 
Ages  cast  their  shadow  over  mankind,  with  other 
sciences  it  sunk  under  the  malign  influences  of 
bigotry  and  superstition.  Astrology,  alchemy, 
and  magic  were  largely  relied  upon  by  the 
theologian-physicians  of  medieval  times. 

With  the  dawn  of  the  Renaissance,  medicine  was 
one  of  the  first  sciences  to  exhibit  signs  of  renewed 
life.  Slowly  but  surely  it  threw  off  the  stupor 
engendered  by  the  murky  air  of  the  supernatural. 
Taking  advantage  of  every  discovery  made  by  its 
sister  sciences,  anatomy,  physiology,  chemistry, 
and  microscopy,  applied  medicine  has  steadily 
gone  forward,  at  first  slowly  and  falteringly,  step 
by  step;  but  gaining  strength  with  every  forward 
step,  the  progress  during  the  last  half  century  has 
been  by  leaps  and  bounds. 

It  is  the  progress  of  these  later  years  which  I  wish 
especially  to  describe,  and  at  the  same  time  to 
explain  the  methods  of  preventing  disease  which 
the  non-professional  may  profitably  know.  The 
trend  of  modern  medical  research  is  largely  in  the 
direction  of  prevention,  and  great  progress  has  been 
made.  The  medical  man  is  almost  alone  among 
the   world's   workers   in   deliberately   cutting   the 


INTRODUCTION  xiii 

ground  from  beneath  his  own  feet,  and  is  striving 
to  make  discoveries  which  will  reduce  his  own 
income.  While  much  in  the  way  of  public  hygiene 
may  be  done  by  the  State  and  municipality  to 
prevent  disease,  equally  important  measures  of 
prevention  rest  with  the  individual.  To  a  certain 
extent,  each  individual  has  his  health  in  his  own 
keeping,  and  can  do  much  to  preserve  or  destroy 
it.  Much  of  the  illness  and  suffering  of  the  world 
results  from  ignorance.  Notwithstanding  the  light 
of  modern  knowledge,  in  medical  matters  many  of 
the  people  are  as  they  who  walk  in  slippery  ways 
of  darkness,  and  they  often  fall  therein. 

Surprise  is  frequently  expressed  that  in  this  age  of 
universal  education  quackery  so  largely  flourishes, 
and  so  many  educated  people  are  led  astray  by 
theories  of  disease  and  treatment  worthy  of  the 
Dark  Ages.  The  reason  is  clear.  Although  popu- 
lar education  covers  almost  every  other  subject, 
it  does  not  include  medicine.  We  frequently, 
therefore,  see  those  of  broad  culture,  great  wisdom, 
and  extensive  learning  in  other  subjects,  holding 
with  childlike  credulity  the  most  absurd  theories 
regarding  the  workings  of  their  own  bodies  and 
the  nature  of  disease.  Great  knowledge  upon  one 
subject  does  not  preclude  dense  ignorance  upon 
another.     The  room  closed  to  the  light  is  in  dark- 


xiv  INTRODUCTION 

ness  though  the  rest  of  the  house  be  filled  with 
sunshine.  Much  light,  it  must  be  acknowledged, 
is  nowadays  offered  upon  medical  subjects,  but,  as 
it  has  been  truly  said,  the  quack  usually  holds 
the  candle. 

The  medical  profession  is  to  a  certain  extent  to 
be  blamed  for  this  state  of  affairs.  It  has  so 
frowned  upon  the  public  discussion  of  medical 
subjects  by  its  own  members  that  the  people  are 
ignorant  of  the  great  and  beneficent  work  it  is  doing. 
To  the  charlatan  and  the  pretender  has  been 
relegated  the  duty  of  giving  popular  instruction 
upon  matters  medical.  In  earlier  times  it  was,  no 
doubt,  a  wise  policy  to  discourage  too  much  public 
discourse  by  medical  practitioners.  The  tempta- 
tion offered  to  the  unscrupulous  to  exploit  them- 
selves is  certainly  great.  The  times,  however, 
have  changed.  The  modern  newspaper  will  not 
cease  to  publish  articles  upon  medical  subjects; 
the  charlatan  will  boast,  and  the  quack  will  adver- 
tise himself.  These  pretenders,  one  and  all,  not 
only  exalt  themselves,  but  by  every  means  in 
their  power  decry  legitimate  medicine  and  its 
conscientious  practitioners. 

As  a  result  of  this  policy  of  the  medical  profes- 
sion there  is  much  popular  misapprehension.  On 
the  one  hand  is  extravagant  faith  in  the  ability  of 


INTRODUCTION  xv 

physicians  and  surgeons  to  do  miracles,  and  on 
the  other  skepticism  or  actual  disbelief  in  their 
ability  to  accomplish  anything.  The  one  state 
of  mind  usually  results  from  the  other,  when 
medical  men  fail  to  accomplish  the  impossible. 
The  following  words  of  Dr.  Andrew  H.  Smith  are 
very  pertinent,  and  are  taken  from  his  recent 
anniversary  discourse  before  the  New  York 
Academy  of  Medicine:  "The  world  has  a  right 
to  know,  and  it  is  our  duty  to  tell,  just  what 
progress  we  are  making  day  by  day,  the  steps 
by  which  results  are  obtained,  the  difficulties  we 
meet,  the  uncertainties  still  to  be  cleared  up,  the 
problems  which  are  pressing  for  solution." 

It  is  here  that  we  find  one  of  the  causes  for  the 
present  widespread  tendency  to  accept  strange 
and  absurd  theories  regarding  disease  and  its  cure. 
The  medical  man  has  not  publicly  boasted  of  his 
successes,  but  has  hidden  his  candle  under  a 
bushel.  Both  the  teacher  and  the  believer  in  the 
many  systems  of  pseudo-medical  science,  however, 
are  prolific  in  discussion,  both  private  and  public. 
Every  success  is  talked  about  and  widely  heralded. 
Not  content  with  a  modest  candle,  they  set  an 
electric  light  on  a  staff  and  maintain  that  they 
light  the  world. 

The    timie    has    come    when    the    medical    man 


xvi  INTRODUCTION 

should  speak,  not  in  his  own  defense,  but  in 
defense  of  the  people,  who  are  easily  misled  to 
their  own  hurt.  He  should  do  this,  not  by  argu- 
ment or  vituperation,  but  by  a  calm  statement 
of  facts  which  shall  set  forth  what  legitimate 
medicine  has  done,  not  alone  to  alleviate  suffering 
and  disease,  but  to  prevent  its  occurrence.  This 
task  I  have  attempted  in  part  to  perform,  and  have 
kept,  I  believe,  strictly  within  the  pale  of  medical 
ethics,  which  are  nothing  more  or  less  than  the 
application  to  medicine  of  the  code  of  honour  of 
gentlemen  the  world  over. 

By  explaining  causes  I  have  attempted  to  show 
to  the  intelligent  reader  the  reasons  for  the  methods 
of  prevention  proposed,  and  why  different  measures 
are  required  for  each  disease.  The  cause  being 
known,  preventive  measures  in  many  instances 
become  self-evident,  and  in  all  cases  can  be  more 
intelligently  carried  out  than  they  could  be  by 
a  blind  following  of  unexplained  rules.  This 
is  the  method  of  all  modern  scientific  research, 
which  seeks  to  discover  causes  and  from  them  to 
deduce  rational  methods  of  prevention  and  cure, 
I  have  thus  endeavoured  to  render  my  readers 
intelligent  upon  subjects  regarding  which  most 
people,  even  the  educated,  are  now  ignorant. 

If  it  be  asked  whether  a  little  knowledge  be  not  a 


INTRODUCTION  xvii 

dangerous  thing,  we  may  reply  with  the  question 
of  the  wise  man,  ''Who,  then,  is  out  of  danger?" 
The  practitioner  who  has  sometimes  seen  a  little 
knowledge  prove  dangerous  has  far  more  fre- 
quently  seen  ignorance  prove  disastrous  and  even 
fatal.    • 


HOW  TO   KEEP  WELL 


CHAPTER  I 

Modern  Medicine 

The  medicine  of  to-day  is  not  altogether 
modern,  nor  is  it  a  science  of  past  centuries. 
Much  that  is  true  and  always  will  be  true  has  come 
to  us  from  the  past,  even  the  ancient  past,  and 
we  of  the  present  generation  have  added  vastly 
to  the  store  of  knowledge.  From  a  restricted 
calling,  medicine  has  developed  into  a  great  pro- 
fession, and  has  entered  upon  a  before  unknown 
stage  of  existence.  There  is  no  other  calling  that 
requires  so  extensive  a  technical  education  to 
insure  the  highest  success.  Taking  the  State  of 
New  York  as  affording  the  best  standard  in  this 
country  for  medical  education,  the  would-be 
medical  student  must  be  a  graduate  from  a  literary 
college  or  he  must  have  an  extensive  preliminary 
education  before  he  can  enter  the  medical  college. 
Here  four  years  of  study  are  required,  after  which 
he  receives  a  diploma  conferring  the  degree  of 
Doctor  of  Medicine.  This  diploma,  however,  is 
not,  as  it  formerly  was,  a  license  to  practise.     To 


2  HOW   TO    KEEP   WELL 

secure  this  license  he  must  pass  an  examination 
before  a  State  board  of  medical  examiners.  Having 
passed  this  ordeal  successfully,  the  young  medical 
man  is  permitted  to  enter  practice,  but  the  more 
ambitious  are  not  content  without  hospital  train- 
ing.    This  requires  two  years  longer. 

Young  Lydgate  is  now  about  twenty-eight  years 
old  and  has  probably  never  earned  a  dollar.  If 
he  entered  college  at  eighteen,  he  graduated  at 
twenty-two  and  left  the  medical  college  at  twenty- 
six.  At  twenty-eight,  therefore,  he  starts  in  life 
as  a  "young  doctor,"  six  years  after  his  chum  of 
the  literary  college  has  started  upon  his  business 
career.  Unless  it  be  through  some  particular 
good  chance,  he  is  fortunate,  if  he  settles  in  a  large 
city,  if  he  is  able  to  support  himself  well  in  five 
years.  The  young  man  ambitious  to  make  a 
fortune  should  certainly  not  adopt  medicine  as 
a  career.  In  any  case,  he  should  be  possessed  of 
some  financial  means  and  a  very  large  stock  of 
pluck  and  endurance. 

The  modern  doctor  is  made  as  well  as  born, 
thus  differing  from  the  poet  and  the  successful 
man  in  many  other  callings.  Natural  ability, 
special  aptitude,  and  love  of  the  work  are  essential 
to  success.  The  time  is  past,  however,  when 
they    alone    can    assure    permanent    success    in 


MODERN    MEDICINE  3 

medicine.  There  is  no  genius  living  who  can 
succeed  in  that  profession  to-day  without  pro- 
longed and  extensive  education.  He  must  sup- 
plement this  education,  moreover,  by  continuous 
work  and  never-ending  study.  The  modern  suc- 
cessful physician  is  the  product  of  the  literary 
college  and  the  medical  school,  the  laboratory  and 
the  post-mortem  room,  the  hospital  and  the  dis- 
pensary. No  quack  relying  on  real  or  supposed 
natural  gifts,  no  seventh  son  of  a  seventh  son,  no 
charlatan  proclaiming  that  he  has  found  the 
secret  of  life  and  the  infallible  cure  of  all  disease, 
succeeds  permanently  to-day.  These  pretenders 
often  make  their  entrance  with  a  flourish,  play 
their  little  parts,  and  sink  out  of  the  public  notice. 
There  is  but  one  road  to  medical  success,  and  that 
is  the  long,  weary  road  of  labour  and  toil,  and  only 
the  few  endowed  with  special  strength  of  mind  and 
body  attain  to  the  highest  places. 

The  subjects  now  going  to  make  medical  knowl- 
edge are  far  more  numerous,  as  well  as  more 
intricate,  than  they  were  even  a  few  decades  ago. 
Anatomy  is  the  basis  of  all  rational  medicine. 
One  of  the  chief  reasons  for  the  slow  progress  of 
medicine  in  earlier  times  was  ignorance  of  anatomy, 
for  until  very  recently  dissection  was  looked  upon 
as  a  desecration  of  the  body.     Even  with  anatomy 


4  HOW   TO    KEEP   WELL 

established  as  an  almost  finished  science,  it  can  be 
learned  only  by  dissection,  and  each  student  must 
learn  it  for  himself.  Of  but  little  less  importance 
than  anatomy  is  physiology,  which  describes  the 
functions  of  the  various  organs.  Chemistry  is 
next  in  importance  among  the  fundamental  studies 
of  the  physician.  The  statement  was  recently 
made  by  a  practitioner  of  one  of  the  new  medical 
sects  that  chemistry  was  unnecessary  in  their 
course  of  study  because  they  used  no  drugs.  This 
was  a  glaring  acknowledgment  of  ignorance. 
One  of  the  most  marked  characteristics  of  the 
quack  is  his  ignorance  of  anatomy,  physiology,  and 
chemistry.  A  knowledge  of  chemistry  is  neces- 
sary to  an  understanding  of  almost  every  organ 
of  the  body.  The  digestive  and  excretory  organs 
in  particular  are  chemical  laboratories  whose 
actions  can  only  be  understood  by  the  light  of 
chemistry.  Moreover,  the  examinations  of  the 
excretions  and  secretions,  so  necessary  to  the 
diagnosis  of  many  diseases,  are  absolutely  de- 
pendent upon  chemical  knowledge.  Physiological 
chemistry  is,  therefore,  one  of  the  necessary 
branches  of  medical  study.  It  is  a  field  in  which 
some  of  the  most  brilliant  discoveries  of  recent 
times  have  been  made.  Histology,  or  minute 
anatomy,  is  the  study  of  the  tissues  of  the  various 


MODERN    MEDICINE  5 

organs,  and  requires  the  microscope  for  most  of 
its  work.  Pathology  is  the  science  of  disease. 
The  work  of  the  pathologist  is  performed  in  the 
post-mortem  room  and  the  laboratory.  In  the 
latter  place  it  consists  chiefly  of  the  microscopic 
study  of  the  diseased  tissues.  While  histology 
deals  with  normal  tissues,  pathology  deals  with 
them  in  their  diseased  forms.  It  is  a  science  of 
vast  proportions,  involving,  as  it  does,  the  many 
diseased  conditions  of  each  of  the  myriad  organs 
and  tissues  of  the  body.  Bacteriology  is  another 
science  of  vast  proportions  and  great  importance, 
and  is  destined  to  become  more  important  and 
more  vast  with  passing  years.  Materia  medica 
describes  the  various  elements  employed  in  the 
treatment  of  disease,  and  deals  largely  with  drugs. 
It  is  closely  associated  with  pharmacy  and  phar- 
maceutic chemistry.  Therapeutics  is  the  science 
of  the  application  of  remedies  to  disease.  It 
includes  not  only  drugs,  but  the  use  of  such 
elements  as  electricity,  water,  heat,  cold,  exercise, 
massage,  diet,  and  a  score  of  other  measures.  It 
is  difficult  for  the  medical  man  educated  in  the 
use  of  these  various  means  of  cure,  each  of  which 
has  its  uses  and  limitations  and  special  advantages 
in  special  cases,  to  comprehend  the  unwisdom  of 
those  faddists  who  deliberately  select  one  as  the 


6  HOW   TO    KEEP   WELL 

only  means  of  treatment  and  throw  all  the  rest 
away.  All  this  is  preliminary  to  what  may  be 
considered  the  practical  subjects — practice  of 
medicine,  obstetrics,  and  surgery,  with  the  eight- 
een  or  twenty  specialties  into  which  they  are 
divided.  It  is  clear  that  the  task  before  the 
young  medical  man  is  not  small. 

A  new  and  peculiar  feature  in  modern  medical 
science  is  the  attention  given  to  post-graduate 
study.  Numerous  schools  have  been  established 
during  the  past  twenty  3^ears  in  which  medical 
practitioners  may  get  out  new  editions  of  them- 
selves, as  one  may  say.  Medical  books  become 
obsolete,  and  after  a  few  years  drop  behind  the 
times,  and  new  editions  must  be  issued.  So  it  is 
with  medical  men.  It  is  easy  to  get  behind  the 
times,  particularly  for  practitioners  away  from 
medical  centres.  Reading  will  do  much  to  pre- 
vent this,  but  there  are  many  things  that  cannot 
be  readily  learned  from  journals  and  books. 
These  schools  are  designed,  therefore,  to  give 
instruction  to  practitioners,  and  the  attendance 
at  them  is  larger  year  by  year.  Their  influence 
in  raising  the  standard  of  practice  throughout  the 
country  has  been  very  apparent. 

A   marked   feature   of   modern   medicine   is   its 
cosmopolitan  character.     It  knows  neither  nation- 


MODERN    MEDICINE  7 

ality  nor  language.  The  work  of  the  medical 
scientist  belongs  to  the  medical  men  of  all 
countries.  The  prominent  medical  journals  of 
every  language  have  a  world-wide  circulation. 
An  important  feature  of  every  journal  is  its 
"abstract"  department,  in  which  is  given  the  pith 
of  all  important  articles  appearing  in  the  medical 
journals  of  the  world.  Those  written  in  foreign 
languages  are  translated,  so  that  the  studious 
physician  is  informed  each  week  of  every  addition 
to  medical  knowledge.  He  is  not  dependent  for 
such  information  upon  the  imperfect  and  often 
sensational  reports  found  in  the  newspapers.  Of 
all  men,  the  well-read  physician  of  to-day  can 
most  truly  say  with  John  Bright,  "My  country  is 
the  world,  my  countrymen  all  mankind." 

The  system  of  trained  nursing  has  had  its 
influence  upon  the  practice  of  medicine,  in  render- 
ing it  more  exact.  The  trained  nurse  is  a  trained 
observer,  by  Vhose  aid  the  attending  physician 
can  obtain  an  understanding  of  an  intricate  case 
he  could  not  otherwise  gain.  The  presence  of  such 
an  observer  adds  also  to  the  safety  of  the  patient 
as  the  case  progresses.  This  training  of  the 
power  to  observe  is  one  of  the  reasons  for  the  pro- 
longed course  of  education  required  of  the  nurse. 
The  details  of  handling  and  managing  the  patient 


8  HOW   TO    KEEP    WELL 

and  administering  treatment  could  be  learned  in 
shorter  time,  but  training  of  the  observation  is  a 
slower  process.  Notwithstanding  the  unpleasant 
experiences  of  some  families  with  indiscreet 
nurses,  the  trained  nurse  is  a  potent  factor  for 
good  in  our  modern  life. 

One  of  the  notable  peculiarities  of  modern 
medicine  is  the  tendency  to  specialism.  In  this, 
however,  it  does  not  differ  from  other  sciences. 
One  sees  much  misapprehension  regarding  the  true 
nature  of  medical  specialism.  There  are  some  who 
suppose  that  a  specialist  is  possessed  of  some 
secret  knowledge  not  known  to  the  profession  at 
large.  They  seem  to  think  that  this  knowledge 
is  transmitted  to  the  few  who  are  favoured  by 
admission  to  the  specialty  as  the  Asclepiadae  of 
old  transmitted  their  knowledge  to  their  descend- 
ants and  followers.  There  could  be  no  greater 
error.  Specialists  are  continually  writing  articles 
descriptive  of  their  work  in  journals  open  to  all 
practitioners,  and  are  discussing  their  theories 
and  methods  openly  in  societies.  The  only  reason 
the  general  practitioner  is  not  as  well  versed  in 
every  detail  of  each  of  these  specialties  is  simply 
the  fact  that  no  human  intellect  can  acquire  and 
retain  all  the  knowledge.  The  specialist  is  a  man 
who,  by  devoting  his  whole  energy  to  a  limited 


MODERN    MEDICINE  9 

number  of  diseases,  acquires  an  especially  intimate 
knowledge  of  them  and  becomes  especially  skilful 
in  their  treatment.  Most  successful  specialists 
were  general  practitioners  in  their  earlier  years. 
As  their  practice  increased  in  some  chosen  direction 
they  curtailed  it  in  others,  and  were  finally  known 
as  experts  or  specialists. 

It  is  clear  that  there  must  be  some  good 
underlying  reasons  or  specialism  would  not  have 
assumed  the  proportions  it  has.  The  chief  of 
these  reasons  is  that  the  science  of  medicine  has 
become  so  vast  that  no  raan  can  attain  to  it  all. 
The  work  of  the  specialist  is  usually  more  satis- 
factory to  himself  than  is  that  of  the  general 
practitioner,  and  is  done  with  less  mental  exertion. 
In  seeing  large  numbers  of  the  same  class  of  cases, 
those  that  are  rare  and  trying  to  the  general 
practitioner  are  to  him  familiar  and  common. 
By  doing  the  same  thing  many  times  he  gains  the 
satisfaction  of  doing  it  particularly  well.  To 
specialism  is  due  in  large  measure  the  develop- 
ment of  modern  medicine  and  surgery.  It  has 
been  the  specialist,  working  along  certain  restricted 
lines,  who  has  gone  ahead  of  his  fellows  and 
discovered  the  great  truths  which  have  made 
medicine  what  it  is  to-day. 

There  are,  on  the  other  hand,  certain  drawbacks 


lo  HOW  TO   KEEP   WELL 

to  the  system  of  specialism.  They  are  not  so 
serious,  however,  that  well-balanced  men  suffer 
materially  from  them.  One  of  the  most  important 
of  these  drawbacks  is  the  tendency  of  the  specialist 
to  magnify  the  importance  of  the  diseases  of  which 
he  sees  so  much,  and  to  belittle  other  causes  of  ill- 
health.  It  is  no  doubt  true  that  there  is  a  tend- 
ency in  specialism  to  narrow  the  field  of  vision, 
and  to  sometimes  lead  the  practitioner  to  overlook 
important  causes  of  disease.  These  criticisms  are 
especially  true  of  those  who  begin  special  practice 
immediately  upon  graduation,  without  the  broad- 
ening influence  of  hospital  training  or  general 
practice.  There  are  large  numbers  of  specialists, 
however,  to  whom  such  criticisms  can  by  no 
means  be  applied. 

Notwithstanding  the  great  advantages  of 
specialism  and  the  important  position  it  has 
obtained,  the  general  practitioner  will  continue  to 
be  a  most  important  element  in  the  medical  pro- 
fession. His  position,  however,  becomes  each 
year  more  difficult.  With  increasing  knowledge 
his  responsibilities  become  greater,  and  more  is 
expected  of  him.  It  is  not  necessary  that  he 
should  be  a  great  anatomist,  physiologist,  chemist, 
pathologist,  and  bacteriologist.  He  must,  how- 
ever, have  a  sound  knowledge  of  all  those  subjects, 


MODERN    MEDICINE  ii 

and  must  be  in  touch  with  the  work  that  is  being 
done  in  all  branches  and  be  able  to  make  a  practical 
application  of  constantly  increasing  knowledge. 
The  general  practitioner  in  the  capacity  of  family 
physician  has  many  duties  to  perform  outside  of 
the  direct  management  of  the  sick  and  the  pre- 
scribing of  treatment.  He  is  to  a  certain  extent 
the  keeper  of  the  family  health,  and  is  frequently 
consulted  upon  the  most  diverse  subjects.  To 
him  the  family  look  for  advice  in  trying  emergen- 
cies, and  often  turn  to  him  as  a  true  man  of  the 
world  in  many  affairs  not  purely  medical.  In  the 
more  strictly  medical  matters  the  trusted  family 
physician  is  the  one  who  must  give  the  final  opinion 
in  many  cases,  even  when  the  advice  of  the  special- 
ist has  been  sought,  for  he  is  looked  upon  as  the 
special  guardian  of  the  interests  of  the  patient. 

To  those  who  would  say  that,  as  medicine  is 
becoming  so  broad  a  science,  all  diseases  should  be 
treated  by  specialists,  a  few  thoughts  may  con- 
vince them  that  this  is  an  extreme  conclusion. 
The  specialist  must  be  more  or  less  a  stranger,  for 
if  such  a  system  were  adopted  the  patient  might 
be  under  the  care  of  half  a  dozen  physicians  in  as 
many  months.  The  family  physician,  who  knows 
the  family,  its  peculiarities  and  hereditary  tenden- 
cies;  who   knows   the   patient,    his   idiosyncrasies 


12  HOW  TO   KEEP   WELL 

and  past  history ;  who  considers  every  aspect  of  the 
case,  will  frequently  reach  a  correct  conclusion 
where  a  man  with  knowledge  of  a  single  class  of 
diseases  will  err.  If  he  be  a  wise  man,  and  seeks 
special  advice  when  special  conditions  arise,  the 
patient's  interests  will  be  much  better  served  than 
they  would  by  a  division  of  attendance.  More- 
over, the  family  physician  has  a  greater  feeling 
of  personal  responsibility,  and  this  is  one  of 
the  most  certain  guarantees  of  the  patient's 
safety. 

A  word  may  be  said  regarding  the  choosing  of  a 
specialist.  It  should  be  done  by  the  family 
physician,  or  at  least  by  a  general  practitioner. 
There  are  differences,  personal  and  professional, 
in  the  specialists  practising  the  same  specialty, 
and  no  one  can  know  so  well  as  the  attending 
physician  who  will  be  best  adapted  to  the  particu- 
lar case  in  hand.  If  the  patient  fears  that  the 
attending  physician  will  select  a  consultant  who 
will  simply  approve  the  treatment  that  has  been 
given,  and  support  the  doctor,  right  or  wrong, 
then  he  had  better  discharge  that  physician  and 
get  one  he  can  trust.  Some  strange  errors  are 
made  in  the  selection  of  specialists  by  patients. 
They  frequently  fall  into  most  incompetent  hands, 
and   sometimes   into   those   of   unscrupulous  men. 


MODERN    MEDICINE  13 

who  have  no  special  knowledge  whatever  of  the 
specialty  they  are  supposed  to  practise. 

The  principles  upon  which  the  family  physician 
is  to  be  selected  are  quite  different  from  those 
which  should  guide  in  selecting  a  consultant. 
Some  excellent  advice  was  given  many  years 
ago  by  Oliver  Wendell  Holmes,  and  was  as 
follows : 

"Choose  a  man  who  is  personally  agreeable, 
for  a  daily  visit  from  an  intelligent,  amiable, 
pleasant,  sympathetic  person  will  cost  you  no 
more  than  one  from  a  sloven  or  a  boor,  and  his 
presence  will  do  more  for  you  than  any  prescrip- 
tion that  the  other  will  order. 

"Let  him  be  a  man  of  recognized  good  sense 
in  other  matters,  and  the  chance  is  that  he  will 
be  sensible  as  a  practitioner. 

"Let  him  be  a  man  who  stands  well  with  his 
professional  brethren,  whom  they  approve  as 
honest,  able,  courteous. 

"Let  him  be  one  whose  patients  are  willing 
to  die  in  his  hands,  not  one  whom  they  go  to  for 
trifles,  and  leave  as  soon  as  they  are  in  danger, 
and  who  can  say,  therefore,  that  he  never  loses  a 
patient." 

To  this  excellent  advice  something  further  may 
be  added,  for  there  are  some  requirements  which 


14  HOW   TO    KEEP   WELL 

to-day  seem  more  important  than  they  would  have 
seemed  thirty  years  ago: 

Let  your  physician  be  a  clean  man,  physically 
and  morally.  Cleanliness  is  now  justly  regarded 
as  an  absolute  requisite  to  success,  in  both  surgical 
and  medical  practice.  Surgical  cleanliness  is, 
in  fact,  the  cleanest  cleanliness  that  has  ever 
been  known.  Beware  of  the  doctor,  therefore, 
with  unclean  hands  and  soiled  clothes.  They 
are  bad  signs.  If  careless  in  matters  so  apparent 
as  this,  he  will  probably  be  careless  in  matters 
that  are  not  apparent.  You  cannot  expect  per- 
fect asepsis  or  antisepsis  from  a  dirty  doctor. 
In  no  other  person  is  there  greater  need  of  these 
biblical  qualities — clean  hands  and  a  pure  heart. 

Let  him  be  a  man  of  character  in  all  to  which 
that  term  applies.  Remember  that  he  must 
come  more  intimately  into  your  family  than  does 
any  other  outside  person.  To  him  you  must 
sometimes  entrust  secrets  known  to  no  other 
living  soul.  You  must  admit  him  to  every  closet 
to  inspect  all  your  family  skeletons.  Only  to  a 
man  of  true  character  should  be  entrusted  the 
many  things  which  you  must  perforce  entrust  to 
your  physician.  He  should  be  a  man  of  such 
magnanimity  and  largeness  of  character  as  to 
hold    inviolable    your    confidences,    even    though 


MODERN   MEDICINE  15 

you  drop  him  and  tell  your  friends  you  would 
not  entrust  him  with  the  health  of  your  dog,  and 
do  otherwise  despitefully  use  him. 

Let  him  be  a  tactful  and  discreet  man.  Though 
he  have  eyes  to  see  and  ears  to  hear,  he  vShould 
see  and  hear  only  those  things  which  you  wish. 
If  he  should,  however,  hear  or  see  more,  he  should 
be  sufficiently  discreet  not  to  talk  to  you  about  it. 

Let  him  not  be  a  man  of  extreme  and  peculiar 
ideas,  or  one  who  practises  by  weird  or  singular 
methods.  Avoid  a  man  with  a  hobby;  he  will 
ride  it  roughshod  sometime  over  your  aching 
bones.  Remember  that  there  is  nothing  to  pre- 
vent a  doctor  who  assumes  the  title  of  physician 
only,  without  attaching  to  it  the  name  of  any 
school  or  dogma,  from  selecting  in  your  treat- 
ment anything  that  he  believes  will  benefit  you. 
Men  who  ostentatiously  adopt  peculiar  modes 
of  treatment,  and  resort  to  extraordinary  methods, 
are  rarely  well  balanced.  Their  judgment  is 
often  at  fault.  You  will  be  safer  with  an  old- 
style,  plodding  doctor  than  with  one  of  these 
modern  faddists,  who  will  experiment  upon  you 
with  extreme  measures  and  untried  methods. 

Let  your  selection  not  be  made  simply  because 
a  doctor  is  "smart."  The  so-called  brilliant 
man  is  often  reckless,  and  prone  to  take  desperate 


i6  HOW   TO    KEEP   WELL 

chances  when  desperate  chances  are  not  required. 
He  is  theatrical,  and  thinks  more  of  exploiting 
himself  than  he  does  of  the  good  of  his  patient. 
Do  not  reject  him  simply  because  he  is  brilliant, 
but  make  certain  that  his  brillianc}^ .  is  tempered 
by  judgment  and  that  there  is  a  well-grounded 
character  behind  it.  No  matter  how  brilliant  he 
may  be,  if  he  be  intemperate,  immoral,  unscrupu- 
lous, rash,  his  patients  will  suffer.  "Genius  and 
character  are  bound  together  by  indissoluble  ties; 
genius  without  character  is  like  oil  that  blazes 
up  and  dies  down  about  a  shattered  lamp." 

When  it  is  possible,  then,  let  your  physician 
be  a  man  of  character — intelligent,  educated, 
tactful,  clean — a  gentleman  who  stands  well  with 
his  professional  brethren  and  has  an  honourable 
record. 

Having  found  such  a  man,  hold  to  him,  and  do 
not  cast  him  aside  for  every  passing  fancy  or 
because  of  minor  shortcomings.  You  will  not 
find  perfection  in  all  things.  After  a  few  years 
of  attendance,  a  physician,  if  he  be  judicious  and 
well  read,  acquires  a  knowledge  of  you  and  your 
family  which  will  result  largely  to  your  benefit. 
If  you  change  your  physician  with  every  illness, 
or  for  every  passing  whim,  or  because  some  friend 
advises   a  better   one,   you   will   certainly   be   one 


MODERN    MEDICINE  17 

of  those  who  have  lost  their  confidence  in  medical 
men  and  are  skeptical  about  the  efficacy  of  treat- 
ment. You  will,  indeed,  find  it  difficult  to  obtain 
a  good  physician,  for  competent  men  with  good 
practice  shun  those  who  are  ever  changing  their 
doctors,  for  they  know  by  experience  that  they 
are  double-minded,  and  unstable  in  all  their  ways, 
and  very  undesirable  patients. 


CHAPTER    II 

The  Causes  of  Disease 

The  cause  of  disease  has  ever  been  a  fruitful 
subject  for  speculation.  The  first  to  promulgate 
a  theory  in  any  degree  rational  was  Hippocrates, 
who  was  born  460  B.  C.  and  is  known  as  the  Father 
of  Medicine.  He  was  both  physician  and  philoso- 
pher. It  was  the  custom  of  that  age  to  divide 
into  sects  or  schools  in  all  questions  of  science, 
philosophy,  and  ethics.  The  two  most  promi- 
nent medical  sects  of  the  Greeks  were  the  dog- 
matic and  the  empiric.  They  are  still  of  interest, 
as  they  outline  fundamental  principles  which  are 
dominant  in  the  medicine  of  to-day. 

The  dogmatic  sect  was  founded  by  Hippocrates 
and  in  its  general  philosophy  was  closely  allied  to 
the  school  of  Pythagoras.  A  conclusion  reached 
by  reasoning  was  of  paramount  value,  although 
the  determining  of  the  causes  of  phenomena  was 
held  to  be  of  great  importance.  Symptoms  were  not 
regarded  as  all-important,  but  the  action  of  the 
organs   from   which   the   symptoms   were   derived 

18 


THE    CAUSES    OF    DISEASE  19 

was  studied.  This  doctrine  has  come  down  to  us 
through  all  the  centuries  and  has  been  the  main- 
spring of  modern  scientific  medicine.  Notwith- 
standing its  imperfections,  which  were  due  in  part 
to  lack  of  knowledge  of  anatomy,  physiology,  and 
chemistry,  it  was  the  most  complete  and  rational 
theory  promulgated  in  ancient  times.  "Like 
everything  else  that  is  good-  and  durable  in  this 
world,  modern  medicine  is  a  product  of  the  Greek 
intellect." 

It  was  the  teaching  of  the  empirical  school  that 
the  cause  of  disease  could  never  be  determined, 
and  that  symptoms  alone  constituted  the  natural 
history  of  an  illness  and  were  the  only  true  guides 
for  the  selection  of  treatment.  Remedies  were 
discovered  by  experiment ;  anatomy  and  physiology 
were  regarded  as  useless.  It  was  a  school  of  pure 
deduction.  Theories  were  evolved  out  of  the 
inner  consciousness  with  complete  disregard  for 
anatomy  and  pathology.  The  one  point  of  wis- 
dom shown  by  this  sect  was  the  value  placed 
upon  experience,  but  it  erred  in  deriving  its  experi- 
ence from  superficial  observation,  which  is  often 
very  misleading.  The  most  prominent  exponent 
of  the  empirical  school  in  modern  times  was 
Hahnemann,  the  founder  of  homeopathy,  who 
adopted  the  theory  that  symptoms  alone  constitute 


20  HOW   TO    KEEP   WELL 

the  only  guide  for  treatment,  and  ridiculed  the  idea 
that  the  cause  of  disease  could  be  determined. 
Had  the  medical  profession  sat  calmly  down  and 
said  that  the  cause  of  disease  could  never  be  dis- 
covered, medical  science  would  now  be  where 
it  was  a  hundred  years  ago.  Empirical  medicine 
has  had  little  share  in  promoting  the  achievements 
of  the  past  fifty  years  and  in  aiding  the  advance- 
ment of  preventive  medicine. 

Other  sects,  based  upon  special  theories  of  dis- 
ease, have  risen  from  age  to  age,  but  have  disinte- 
grated and  passed  away,  though  the  faint  imprints 
of  some  may  be  seen  to  the  present  day.  When 
founded  upon  some  real  scientific  truth,  the  truth 
lives  after  the  sect  is  dead,  as  the  spirit  survives 
the  body.  These  truths  one  after  another  have 
become  incorporated  into  the  great  mass  of  medical 
knowledge,  while  the  sects  built  up  around  them 
have  been  forgotten.  This  has  been  the  fate 
sooner  or  later  of  all  sects  and  schools  founded 
upon  single  dogmas.  The  medical  profession  is 
not  founded  upon  any  one  theory  of  disease  or 
dogma  of  practice,  but  adopts  everything  which, 
when  weighed  in  the  balance,  is  found  not  wanting. 
Its  practitioners  may  honestly  select  anything 
from  the  whole  field  of  medicine.  They  are  not 
restricted  by  any  single  theory  or  system  or  motto 


THE    CAUSES    OF    DISEASE  21 

of  practice.  A  diploma  which  confers  the  title  of 
Doctor  of  Medicine  confers  the  legal  and  moral 
right  to  employ  any  known  means  for  the  diag- 
nosis and  treatment  of  disease. 

During  the  medieval  ages  the  authority  of 
Galen  was  supreme  in  medicine.  His  teaching 
was  based  upon  that  of  Hippocrates.  There  is 
nothing  in  history  to  compare  with  the  influence 
which  Galen  held  in  matters  medical  except  the 
influence  of  Ptolemy  in  matters  astronomical. 
Both  lived  at  about  the  same  time,  and  the  systems 
promulgated  by  each  were  regarded  with  almost 
the  reverence  accorded  to  the  Scriptures.  In 
fact,  the  expression  of  opinions  different  from 
those  taught  by  these  two  men  was  punished  by 
the  Church.  After  the  death  of  Galen,  about 
200  A.  D.,  for  thirteen  centuries  medical  science, 
like  every  other  science,  was  stagnant.  Then 
began  the  age  of  restoration,  when  science  in  all 
its  branches  threw  off  the  blighting  influence  of 
blind  reliance  upon  the  authority  of  one  man.  At 
the  present  day  the  opinions  of  certain  scientific 
observers  are  held  in  high  respect,  but  there  is  no 
such  thing  as  a  scientific  or  medical  authority  in 
the  old  sense.  A  man's  theories  are  now  accepted 
when  he  proves  them  to  be  true,  not  because  he 
says  they  are  true. 


22  HOW   TO    KEEP   WELL 

One  of  the  most  important  events  of  modern 
medicine  was  the  announcement  of  the  theory  of 
cellular  pathology  by  Virchow  in  1858.  By  this  is 
meant  that  all  vital  processes  issue  from  cells. 
Vital  force  is  a  name  given  to  that  essence  of  life 
whose  nature  we  do  not  yet  understand  and 
perhaps  never  will.  By  the  older  theory  it  was 
supposed  to  be  distributed  through  ♦the  body 
or  located  in  the  organs  as  a  whole.  By  Virchow's 
theory  the  animal  body  is  regarded  as  an  aggre- 
gation of  cells,  each  of  which  has  a  unity  and  life 
of  its  own.  As  a  nation  is  a  unit  composed  of 
individuals,  each  having  his  own  personality,  living 
his  own  life,  and  performing  his  own  part  in  the 
work  of  the  whole,  so  living  bodies  are  composed 
of  individual  cells  in  which  the  vital  force  resides. 
By  this  theory  the  understanding  of  disease  has 
been  enormously  advanced.  At  first  proposed  as 
an  hypothesis,  it  has  been  accepted  by  the  scientific 
world,  and  is  the  basis  of  all  modern  medical 
thought. 

The  discovery  of  the  bacteriological  origin  of 
certain  diseases  is  a  chapter  by  itself.  It  was  not 
an  accident,  nor  was  it  a  single  discovery  by  a 
single  observer.  It  was  the  last  link  of  a  long 
chain.  Not  one  link  could  have  been  omitted,  and 
it  does  not  seem  possible  that  the  different  discov- 


THE    CAUSES    OF    DISEASE  23 

eries  in  the  series  could  have  been  made  much 
sooner  than  they  were.  Each  discovery  led  to  the 
next  and  each  was  dependent  upon  what  had  gone 
before.  Soon  after  the  invention  of  the  microscope 
in  the  latter  part  of  the  sixteenth  century,  some  of 
the  larger  bacteria  were  seen,  but  their  true  char- 
acter was  not  then  suspected.  Successive  improve- 
ments of  the  microscope  were  marked  by  successive 
discoveries  in  bacteriology. 

Were  one  to  write  a  history  of  bacteriology,  he 
would  be  obliged,  also,  to  almost  write  the  biog- 
raphy of  Pasteur,  so  closely  is  he  associated  with  all 
the  earlier  work  in  that  science.  In  1863  he  pub- 
lished his  first  great  work,  which  established  the 
fact  that  fermentation  and  putrefaction  are  due 
to  micro-organisms.  The  theories  he  then  pro- 
mulgated, and  which  are  now  universally  accepted, 
were  revolutionary  in  the  extreme.  This  work 
was  the  foundation  of  the  present  germ  theory 
of  disease.  It  was  the  inspiration  of  all  the  bac- 
teriological work  which  has  since  been  done,  and 
gave  the  death  blow  to  the  old  theory  of  spon- 
taneous generation.  Pasteur  was  a  patient  and 
untiring  observer  and  collector  of  facts.  This 
is  an  important  qualification  of  a  scientist,  but  alone 
is  of  but  little  value.  He  possessed  in  addition  to 
this  the  power,  amounting  to  genius,  of  generaliza- 


24  HOW   TO    KEEP   WELL 

tion  and  drawing  correct  conclusions  from  the 
facts  he  observed.  No  other  man  has  excelled 
him  in  this,  except  possibly  Darwin.  He  was 
never  in  a  hurry  to  publish  a  result  until  its  truth 
had  been  absolutely  proved. 

Unlike  many  laboratory  workers,  Pasteur  was 
eminently  practical,  and  his  researches  have  already 
resulted  in  incalculable  benefit  to  the  human  race. 
A  single  example  will  illustrate  this.  In  1865 
the  silk  industry  of  France  produced  a  revenue  of 
130,000,000  francs.  Owing  to  a  disease  in  the  silk 
worm,  it  fell  in  a  few  years  to  8,000,000  francs,  and 
the  industry  was  threatened  with  annihilation. 
Pasteur  was  appealed  to  and  undertook  the  study 
of  this  disease.  Abandoning  his  cherished  work, 
he  entered  with  all  his  strength  into  its  study,  and 
after  long  research  discovered  that  the  disease 
was  due  to  a  micro-organism  which  affected  the 
worm,  the  moth,  and  the  egg.  He  suggested 
a  remedy,  and  after  a  short  time  the  silk  industry  of 
France  was  restored  to  its  original  prosperity.  A 
few  years  later  the  wine  industry  of  France  was 
threatened  with  ruin,  owing  to  an  unexplained 
fermentation  in  the  wine.  This  was  investigated 
by  Pasteur,  the  cause  was  discovered,  and  the 
industry  was  saved.  Important  as  this  work 
was  in  its  immediate  results,  the  remote  results 


THE   CAUSES   OF   DISEASE  25 

were  more  important,  for  it  gave  him  an  insight 
into  the  genesis  of  infectious  diseases. 

Pasteur's  results  were  largely  secured  by  animal 
experimentation.  It  was  natural,  therefore,  that 
he  should  first  study  the  infectious  diseases  from 
which  animals  suffer.  He  thus  studied  and  traced 
to  their  cause  splenic  fever,  fowl  cholera,  swine 
fever,  and  hydrophobia.  He  discovered  many 
facts  regarding  suppuration  and  the  infection  of 
wounds.  His  whole  method  of  work  being  that 
of  actual  experimentation,  chiefly  with  animals,  he 
did  not  discover  any  of  the  germs  of  diseases 
affecting  the  human  race,  but  his  work  established 
the  germ  theory  of  disease  more  thoroughly  than 
it  could  have  done  had  it  been  limited  to  the 
human  subject. 

The  earlier  work  of  Pasteur  was  supplemented 
by  that  of  many  expert  observers,  one  of  the 
most  notable  being  Professor  Tyndall,  who  carried 
out  extensive  studies  upon  living  germs  in  the  air. 
He  demonstrated  the  presence  of  bacterial  clouds 
which  are  blown  hither  and  thither  by  the  wind, 
so  that  it  is  impossible  to  expose  a  culture  medium 
even  in  the  open  country  without  taking  up  quan- 
tities of  living  germs.  The  greatest  student  of  the 
germs  which  produce  disease  in  the  human  body 
is  Koch,   of  Berlin.     Being  a  younger  man   than 


26  HOW  TO   KEEP   WELL 

Pasteur,  and  following  him  in  his  discoveries,  he 
has  done  more  than  any  one  else  to  devise  methods 
of  cultivating  germs  artificially  and  isolating 
each  species  so  that  they  may  be  studied  in 
"pure  cultures."  He  discovered  the  bacterium 
of  tuberculosis  in  March,  1884,  and  the  bacterium 
of  cholera  not  long  after. 

For  several  years  the  subject  of  bacteriology 
was  in  a  chaotic  state,  and  every  discovery  was 
looked  upon  with  distrust  by  the  conservative 
portion  of  the  medical  profession,  who  would 
accept  no  statement  until  proved.  Gradually, 
by  the  most  laborious  effort,  one  landmark  after 
another  was  established,  and  fact  after  fact  was 
proved,  until  to-day  no  intelligent  physician 
questions  the  importance  of  bacteria  in  the  causa- 
tion of  a  large  number  of  diseases.  A  portion  of  a 
vast  field  has  been  surveyed,  but  no  one  can  tell 
how  much  lies  beyond  or  what  the  future  may 
reveal. 

The  error  should  not  be  made  of  thinking  that  all 
disease  is  caused  by  bacteria.  There  are  numer- 
ous other  causes,  some  originating  outside  of  the 
body  and  others  within  it.  Those  originating 
without  the  body  are  substances  of  an  irritating  or 
poisonous  nature  capable  of  causing  abnormal 
local  or  constitutional   conditions.     Among  these 


THE    CAUSES   OF   DISEASE  27 

are  materials  used  in  certain  trades,  like  arsenic 
and  mercury,  or  certain  drugs  like  opium  and 
alcohol,  or  poisonous  plants.  Those  originating 
within  the  body  are  the  products  of  the  perverted 
action  of  certain  organs,  or  the  absorption  of  normal 
injurious  products  which  are  not  properly  excreted. 
There  are  many  diseases  of  this  class.  Disease 
may  also  result  from  certain  mechanical  causes,  as 
excessive  heat,  cold,  moisture,  or  dryness,  or  from 
physical  injury. 

Diseases  do  not  result  from  a  single  cause,  and 
they  cannot  be  cured  by  any  single  method  of 
treatment.  The  philosopher's  stone  and  the  foun- 
tain of  youth  still  lie  concealed  in  some  undis- 
covered country.  When  they  are  found  we  may 
reasonably  seek  the  panacea  for  all  human  ills. 


CHAPTER  III 

Bacteria 

Bacteria  play  a  role  of  vast  importance  in  the 
economy  of  nature.  Most  species,  of  which 
there  are  unnumbered  thousands,  are  the  bene- 
factors rather  than  the  enemies  of  mankind. 
They  are  the  scavengers  of  nature,  whose  office 
it  is  to  remove  dead  organic  matter  and  convert 
it  into  simple  and  harmless  chemical  compounds. 
All  fermentation,  decomposition,  putrefaction, 
and  decay  are  caused  by  bacteria  or  their  near 
relatives,  the  yeasts  and  moulds.  It  is  largely  by 
the  action  of  bacteria  that  the  upper  layers  of 
the  soil  are  transformed  into  fertile  land  fit  for 
the  production  of  crops.  Numerous  processes  of 
animal  and  vegetable  life  are  wholly,  or  in  large 
part,  dependent  upon  bacterial  action.  Notwith- 
standing the  fact  that  some  bacteria  are  among 
the  greatest  enemies  of  man,  were  all  species  to  be 
destroyed  he  would  lose  more  than  he  would  gain. 
It  is  not,  however,  these  harmless  or  benign  bacteria 
which    we    are    to    consider     in    this    place,   but 

28 


BACTERIA  29 

rather  the  comparatively  small  number  of  disease- 
producing  germs  known  as  pathogenic  bacteria. 

Bacteria  are  often  referred  to  as  worms  or  bugs, 
and  it  is  a  common  belief  that  they  are  minute 
animals.  This  is  not  the  fact.  They  belong  to 
the  lowest  order  of  plant  life,  being  relatives  of  the 
fungi  and  moulds.  They  are  mere  cells,  or  specks 
of  living  matter,  so  minute  that  their  examina- 
tion taxes  the  utmost  powers  of  the  microscope. 
The  micromillimeter,  equivalent  to  about  1-25,000 
of  an  inch,  is  taken  as  the  unit  of  measurement. 
This  means  that  25,000  bacteria  could  lie  side  by 
side  in  the  space  of  one  inch.  The  smallest  germs 
are  about  one-tenth  of  this  unit  in  diameter. 
Under  the  microscope  bacteria  appear  much  like 
little  periods,  commas,  or  dashes.  There  is  not  a 
bacterium  known  which  has  a  fierce  or  animal-like 
appearance,  like  that  sometimes  portrayed  in 
patent  medicine  advertising.  They  are  simply 
single-celled  plants,  and  are  usually  classed  with 
the  fungi.  They  obtain  their  food  by  simple 
surface  absorption. 

Bacteria  multiply  by  a  process  called  fission. 
When  it  reaches  a  certain  age,  the  bacterium 
elongates  and  a  depression  appears  near  the  centre. 
This  increases  until  the  original  germ  is  divided 
into  two.      Others  divide  irregularly  in   all  direc- 


so  HOW   TO    KEEP   WELL 

tions  and  produce  clusters  of  cells.  Some  germs 
also  reproduce  themselves  by  means  of  spores. 
A  spore  is  a  minute  granule  which  forms  within  a 
germ,  and  has  the  power  of  developing  a  germ 
similar  to  the  parent,  as  the  seed  produces  a  plant. 
These  spores  are  extremely  tenacious  of  life,  and 
withstand  drying  and  great  extremes  of  heat  and 
cold.  Germs  which  multiply  by  spores  are  far 
more  difficult  to  destroy,  therefore,  than  those 
which  do  not.  Some  germs  fissure  every  t went 3^ 
minutes.  If  they  do  so  but  once  an  hour,  a  vsimple 
mathematical  computation  demonstrates  that 
16,777,216  germs  may  look  back  to  a  common 
ancestor  who  flourished  in  a  bygone  age  twenty- 
four  hours  before,  not  to  speak  of  the  intervening 
generations  that  have  perished.  If  such  a  germ 
be  a  producer  of  poison,  it  is  not  difficult  to  under- 
stand that  disease  may  result  from  organisms 
which  multiply  at  such  a  terrific  rate. 

In  order  that  most  varieties  of  bacteria  may  be 
seen  and  studied,  improved  and  powerful  micro- 
scopes are  required,  fitted  with  delicate  and  expen- 
sive appliances.  Even  with  these,  most  germs 
must  be  stained  and  specially  prepared  before 
they  can  be  studied.  It  has  been  found  that  the 
aniline  dyes  have  a  remarkable  power  of  colouring 
bacteria.     Each  species  has  a  selective  power,  and 


BACTERIA  31 

is  affected  by  certain  dyes  in  a  peculiar  manner. 
Thus,  under  proper  treatment  each  germ  assumes 
its  own  pecuHar  appearance.  This,  even  more 
than  its  shape  and  size,  frequently  aids  in  its  recog- 
nition. The  ability  to  isolate  one  species  of 
bacteria  from  every  other  species,  to  cultivate  it 
and  to  study  its  life  history  and  growth,  is  one  of 
the  greatest  triumphs  of  scientific  research.  For 
these  results  we  are  largely  indebted  to  the  genius 
of  Robert  Koch. 

All  germs  require  moisture  for  their  develop- 
ment, with  suitable  temperature  and  pabulum. 
Light,  as  a  rule,  is  not  favourable  to  their  growth. 
Cold  arrests  the  growth  of  all  micro-organisms, 
but  the  lowest  degree  attainable  does  not  destroy 
the  vitality  of  certain  species.  Heat,  on  the  other 
hand,  is  a  very  potent  germicide.  All  known 
pathogenic  germs  are  killed  by  heat  far  below  the 
boiling  point. 

Having  learned  to  isolate  a  germ  from  the  body 
and  cultivate  it,  we  are  prepared  to  study  its 
action  in  the  causation  of  disease.  Four  postulates 
are  formulated  by  Koch  as  being  necessary  to 
prove  that  a  given  bacterium  is  the  cause  of  a 
certain  disease,  i.  It  must  be  found  in  the 
tissues  or  secretions  of  an  animal  suffering  from  the 
disease.     2.  It  must  be  cultivated  outside    of   the 


32  HOW   TO    KEEP    WELL 

body  in  an  artificial  medium,  all  other  germs 
being  excluded.  3.  This  culture  must  produce 
the  same  disease  when  inoculated  into  the  body  of 
a  healthy  animal,  susceptible  to  the  disease. 
4.  The  same  germ  must  then  be  found  in  the  body 
of  the  animal  so  inoculated.  These  four  require- 
ments have  been  fulfilled  in  many  diseases.  A 
few  are  believed  to  be  due  to  certain  germs, 
although  all  the  requirements  have  not  yet  been 
fulfilled.  Typhoid  fever,  for  example,  does  not 
occur  in  any  animal.  The  evidence,  however, 
is  so  convincing  that  it  is  due  to  a  certain  bacillus, 
that  that  bacillus  is  accepted  as  the  cause,  although 
it  has  been  impossible  to  take  all  the  steps  pro- 
posed by  Koch. 

The  relation  of  these  microscopic  bodies  to  a 
given  disease  being  found,  the  question  arises: 
How  do  they  produce  this  result  ?  The  bacteria 
themselves  h&ve  but  little  effect;  they  act  chiefly 
by  the  production  of  poisonous  principles  known 
as  toxins.  By  a  subtle  chemistr}'  they  decom- 
pose the  elements  by  which  they  are  surrounded 
to  form  new  compounds.  Some  of  these  are 
poisonous  and  produce  the  phenomena  known 
as  disease ;  by  far  the  greater  number  are  harmless. 
There  is  nothing  peculiar  in  this  action.  Every 
living   cell    appropriates   certain   elements   for   its 


BACTERIA  33 

nutrition  and  excretes  certain  other  elements, 
and  bacteria  cells  form  no  exception  to  this  rule. 
If  these  products  of  excretion  are  harmless  to  the 
animal  body  the  germ  is  benign.  If  they  are 
poisonous  the  germ  is  known  as  pathogenic.  The 
growth  of  many  of  the  higher  orders  of  plants 
results  in  similar  chemical  changes,  as  seen  in  the 
action  of  yeast  in  the  process  of  bread-making  and 
of  brewing. 

Various  micro-organisms  act  as  ferments.  One 
produces  lactic  acid  from  milk,  another  acetic  acid 
from  alcohol.  Putrefaction  is  the  result  of  the 
action  of  certain  germs  upon  albuminous  material, 
the  product  being  of  offensive  odour.  Some 
substances,  like  milk,  are  subject  to  various  forms 
of  fermentation,  for  some  germs  act  upon  the  milk 
sugar  and  others  upon  the  casein.  By  fermen- 
tation is  meant  the  decomposition  of  special  com- 
pounds of  the  starch  and  sugar  class.  Numerous 
phenomena  of  nature  are  also  caused  by  the  action 
of  bacteria.  The  phosphorescence  which  some- 
times results  from  decaying  vegetable  and  animal 
matter  is  directly  due  to  them.  Certain  germs 
cause  a  greenish  or  bluish  florescence,  which  gives 
colour  to  some  bodies  of  water.  The  miracle  of 
the  "bleeding  host,"  in  which  bread  becomes 
covered  with  a  red  substance  like  blood,  is  also 


34  HOW   TO    KEEP    WELL 

the  result  of  such  action.  The  red  substance 
consists  of  masses  of  the  germ  known  as  the  bacillus 
prodigiosus. 

The  poisons  produced  by  pathogenic  germs 
are  known  as  toxins.  They  are  of  two  classes. 
Those  of  the  simple  class  are  capable  of  causing 
fever  and  inflammation.  The  others,  known  as 
toxalbumins,  are  among  the  most  intensely  poi- 
sonous substances  known.  Many  of  these  toxins 
have  been  so  far  isolated  that  their  action  could 
be  partially  studied.  Some  of  them  are  of  almost 
inconceivable  virulence,  being  many  hundred 
times  more  poisonous  than  morphine  or  strychnine. 
They  are  so  active,  in  fact,  that  it  is  now  believed 
that  some  of  them  are  of  the  nature  of  ferments. 
It  is  the  continuous  formation  of  these  toxins 
which  produces  those  results  known  as  infectious 
diseases.  Such  diseases  are,  therefore,  nothing 
more  nor  less  than  conditions  of  acute  poisoning. 

Certain  substances  formed  by  the  action  of 
bacteria  upon  nitrogenous  matter  are  known  as 
ptomaines.  These  ptomaines  are  mostly  active 
poisons,  and  may  be  formed  outside  the  body. 
Certain  germs  acting  upon  milk  develop  a  virulent 
ptomaine  known  as  tyrotoxicon.  This  is  the 
cause  of  ice-cream  poisoning  so  frequently  reported 
during    the    summer    months.     It    results    from 


BACTERIA  35 

improper  care  of  milk  from  which  the  cream  is 
made.  The  symptoms  simulate  those  of  arsenic 
poisoning.  The  summer  diarrheas  of  children, 
which  destroy  so  many  infant  lives,  are  largely  the 
result  of  ptomaines  formed  in  the  milk  upon  which 
they  are  fed.  There  are  poisonous  substances 
sometimes  formed  within  the  body  itself,  known 
as  leucomaines,  which  result  in  a  sort  of  self- 
poisoning  or  auto-infection. 

Bacteria  are  classified  according  to  their  forms 
and  appearance,  the  most  common  being  bacilli, 
spirilli,  and  cocci.  A  bacillus  is  a  rod-shaped 
germ  having  rounded  or  pointed  ends.  A  spirillum 
is  a  long,  twisted  germ,  sometimes  having  a  very 
regular  spiral  form.  A  micrococcus  is  a  spherical 
body,  and  appears  as  a  mere  dot.  Micrococci  are 
classified  according  to  their  groupings  as  follows: 
staphylococci,  which  grow  in  clusters  like  grapes; 
streptococci,  which  grow  in  chains  like  strings  of 
beads;  diplococci,  which  grow  in  pairs;  and  sar- 
cinse,  which  form  cube-shaped  groups.  Each 
germ  has  its  own  individual  name,  usually  a  long 
one.  For  example,  the  little  body  concerned  in 
the  formation  of  pus  glories  in  the  title  staphy- 
lococcus pyogenes  aiiretis. 

Bacteria  are  also  classified  according  to  their 
habits  of  life,  as  saproph3rtes  and  parasites.     The 


36  HOW   TO    KEEP   WELL 

first  develops  independently  of  a  living  host, 
usually  in  decaying  vegetable  or  animal  material. 
The  second  develops  only  in  the  living  body.  A 
facultative  saprophyte  develops  in  both  living  and 
dead  animal  tissue.  Such  germs  are  particularly 
hard  to  combat.  If  deposited  in  a  favourable 
place  outside  the  body,  they  may  reproduce  them- 
selves indefinitely,  and  thus  infect  a  constantly 
increasing  area  and  retain  their  vitality  for  an 
unlimited  time.  All  disease-producing  germs  are 
either  strict  parasites  or  facultative  parasites. 
The  saprophytes  make  up  the  great  mass  of  germs 
beneficial  to  man.  The  most  of  them  do  not 
generate  poisons.  A  few,  however,  do  this,  but  do 
not  produce  disease,  as  do  the  parasites.  The 
poisons  are  formed  outside  the  body,  but  may  be 
taken  into  the  body  like  any  other  poison.  Some 
of  the  putrefactive  bacteria  are  germs  of  this  class. 
The  term  "blood  poisoning"  is  a  popular  expres- 
sion used  to  cover  a  variety  of  conditions.  It  may 
mean  toxemia,  the  absorption  of  the  poisonous 
products  of  germs  from  a  local  point  of  infection, 
no  germs  being  found  in  the  blood  or  tissues.  It 
is  sometimes  used  also  to  mean  septicemia,  which 
is  not  alone  the  absorption  of  toxines,  but  the 
invasion  of  the  system  by  bacteria.  It  is  some- 
times  used,    also,    to    indicate   the    absorption   of 


BACTERIA  37 

leucomaines — poisoning  elements  formed  within 
the  body  itself.  It  is  even  used  sometimes  to 
denote  the  poisoning  of  the  body  by  ptomaines. 
It  is  thus  seen  that  the  term  as  popularly  used  is 
a  very  indefinite  one. 

It  being  granted  that  certain  germs  are  the 
cause  of  a  disease,  does  it  necessarily  follow  that 
every  person  exposed  to  those  germs  will  contract 
the  disease  ?  By  no  means.  Germs  are  in  their 
essential  qualities  seeds,  and  seeds  require  a  soil 
for  their  growth.  If  they  fall  by  the  wayside  they 
take  no  root.  Upon  stony  ground  forthwith  they 
spring  up,  but  wither  away;  among  thorns  they  are 
choked.  Only  upon  good  ground  will  seeds  or 
germs  bring  forth  fruit.  As  each  seed  requires  a 
peculiar  soil  for  its  fullest  development,  each 
according  to  its  kind,  so  germs  require  peculiar 
conditions  for  their  growth.  The  physician  recog- 
nizes, therefore,  two  causes  of  disease,  predis- 
posing and  exciting — the  soil  and  the  seed. 
The  germs  of  diphtheria  lodge  in  the  throat  of  a 
healthy  adult.  The  seeds  fall  by  the  wayside  and 
take  no  root.  Other  germs  lodge  in  the  throat  of 
a  child  who  has  been  immunized  by  antitoxin. 
The  seeds  have  fallen  among  thorns,  and  the 
thorns  spring  up  and  choke  them.  Other  germs 
lodge   in   the   throat   of   a   child   with   sound   and 


SS  HOW   TO    KEEP   WELL 

healthy  mucous  membranes.  The  seeds  fall  upon 
stony  places  and  forthwith  they  spring  up  but  soon 
wither  away.  And  still  other  germs  lodge  in  the 
throat  of  a  child  with  enlarged  tonsils,  adenoids, 
and  chronic  catarrh.  The  seeds  fall  upon  good 
ground  and  grow  luxuriously  in  a   congenial   soil. 

Predisposing  causes  are  important  but  often 
extremely  obscure  and  difficult  of  detection.  It 
has  been  proved  that  animals  which  have  not 
taken  a  disease  when  inoculated  while  in  perfect 
health,  have  quickly  succumbed  after  a  prolonged 
fast  or  when  exhausted  by  excessive  exercise. 
There  is  truth  in  the  common  belief  that  a  con- 
tagious disease  is  more  readily  contracted  "on  an 
empty  stomach"  or  when  the  power  of  resistance 
is  lessened  by  fatigue.  Heredity  is  often  an 
important  predisposing  cause,  but  very  few 
diseases  are  actually  inherited.  Hereditary 
influence  consists  of  peculiar  conditions  of  the 
body  tissues  which  render  them  especially  suscep- 
tible to  the  assaults  of  germs.  The  soil  may  be 
rich,  but  there  is  no  vegetation  without  seeds;  the 
hereditary  tendency  may  be  strong,  but  there  is  no 
infectious  disease  without  germs. 

The  older  theory  that  the  infectious  diseases 
may  sometimes  occur  through  spontaneous  gen- 
eration is  absolutely  untenable.     The  source  from 


BACTERIA  39 

which  the  bacilH  are  derived  in  sporadic  cases  is 
often  obscure.  It  is  as  absurd  to  suppose,  how- 
ever, that  a  distinct  variety  of  bacillus  can  generate 
itself  from  nothing,  as  to  expect  that  a  plant  will 
grow  in  one's  garden  without  seed  or  planting. 
If  a  strange  weed  or  flowering  plant  does  appear, 
we  conclude  that  some  stray  seed  has  been  dropped 
unknown  to  us.  And  so  sporadic  cases  of  disease 
develop  here  and  there,  but  whence  they  come  we 
may  oftentimes  never  know.  There  being  no 
spontaneous  generation  of  infectious  diseases, 
there  can  be  no  "filth  diseases"  in  the  old  sense  of 
the  term.  No  extreme  of  filth  can  cause  a  specific 
infectious  disease  without  implanting  in  the  filth 
the  germ  of  that  disease. 

The  body  has  not  been  left  entirely  unprotected 
and  wholly  at  the  mercy  of  pathogenic  germs.  It 
has  remarkable  powers  of  resistance,  differing 
with  different  individuals.  The  acid  secretions 
of  the  stomach  kill  some  germs.  Certain  elements 
of  the  blood  have  to  a  marked  degree  the  power 
of  destroying  others.  Beyond  a  certain  point  this 
power  ceases  and  disease  results.  Exposure  does 
not  necessarily  mean  infection. 

Immunity  from  contagious  diseases,  though  the 
subject  of  much  investigation,  is  still  an  obscure 
one.     Some   species    of   animals    are   insusceptible 


40  HOW   TO    KEEP   WELL 

to  germs  which  are  very  fatal  to  other  species. 
Most  sheep  are  very  susceptible  to  anthrax,  but 
Algerian  sheep  rarely  if  ever  contract  it.  There 
is  also  a  racial  inimunity  which  renders  certain 
races  almost  immune  to  certain  diseases.  The 
Chinese  show  a  marked  immunity  from  cholera. 
The  Jews  show  a  most  conspicuous  immunity  from 
tuberculosis  and  acute  epidemic  diseases.  There 
is  still  further  a  personal  tolerance  which  is  very 
noticeable.  The  young  of  all  animals  are,  as  a 
rule,  more  susceptible  to  infectious  diseases  than 
are  the  old. 

A  subject  of  the  greatest  practical  interest  and 
one  upon  which  a  vast  amount  of  labour  has  been 
expended,  is  that  of  acquired  immunity.  By  this 
is  meant  the  immunity  which  commonly  follows  an 
attack  of  a  contagious  disease.  Closely  allied  to 
this  is  the  immunity  which  we  have  recently 
learned  to  confer  in  a  few  diseases  by  the  adminis- 
tration of  antitoxin.  Owing  to  the  fact  that  it  is 
so  closely  interwoven  with  physiological  chemistry 
and  with  the  whole  fabric  of  bacteriology,  it  is  a 
most  difficult  subject  to  elucidate  in  a  popular 
manner.  It  will  be  discussed  at  greater  length 
in  the  chapter  on  antitoxins.  It  is  sufficient  here 
to  say,  that  after  the  toxin  is  generated  by  the 
bacteria,  through  some  action  either  of  the  body 


BACTERIA  41 

tissues  or  of  the  blood  serum  not  yet  positively 
determined,  another  element  is  gradually  formed, 
antidotal  to  the  toxin,  and  apparently  destructive 
to  the  bacteria  themselves.  To  this  element  has 
been  given  the  name  of  antitoxin.  Were  it  not 
for  some  such  action,  every  infectious  disease 
would  be  fatal.  The  bacteria  would  steadily 
multiply  and  produce  a  constantly  increasing 
amount  of  toxin,  and  the  time  would  necessarily 
come  when  no  human  organism  could  withstand 
its  poisonous  effects. 

Increased  knowledge  regarding  bacteria  and 
their  action  in  producing  disease  renders  it  more 
and  more  probable  that  but  little  is  to  be  expected 
in  the  actual  prevention  and  cure  of  the  infectious 
diseases  from  any  known  chemical  compound  or 
antiseptic:  They  are  either  poisonous  to  the 
animal  body,  or  are  decomposed  and  rendered 
inert  before  they  reach  the  germs  at  the  seat  of  the 
disease.  Hope  seems  to  lie  in  our  ability  to  obtain 
certain  curative  elements  resulting  from  the  action 
of  the  germs  themselves.  It  is  in  this  direction 
that  the  most  active  work  is  being  done  and  from 
which  the  most  important  results  are  to  be  expected,- 

There  are  a  few  micro-organisms  belonging 
to  the  animal  kingdom  that  are  capable  of  causing 
disease  in  man.     The  most  notable  of  these  are 


42  HOW   TO    KEEP   WELL 

the  plasmodiwin  jnalaricB,  and  certain  ameba  which 
are  capable  of  causing  dysentery.  The  Plasmo- 
dium develops  within  the  red  blood  cells  and  is 
an  organism  of  extraordinary  interest.  It  is  easy  of 
study,  and  its  life  history  is  well  known.  It  will 
be  described  in  detail  under  the  subject  of  malaria. 
The  astronomer  and  bacteriologist  work  upon 
opposite  sides  of  the  great  field  of  scientific  research, 
the  one  with  the  telescope,  the  other  with  the 
aaicroscope.  Both  use  units  of  measurement 
almost  incomprehensible  to  the  human  mind,  one 
from  its  vastness,  the  other  from  its  minuteness. 
The  astronomer  makes  his  calculations  in  thousands 
of  miles,  the  bacteriologist  in  thousandths  of  an 
inch.  The  one  studies  worlds  unseen  by  the  natural 
eye,  the  other  infinitesimal  cells.  The  cells,  how- 
ever, are  as  real  and  tangible  as  are  the  worlds, 
and  probably  of  more  importance  to  us  of  this 
earth.  They  are  numbered,  not  in  scores  or 
hundreds,  but  in  millions.  Comparisons  are  odious. 
But  one  can  scarcely  refrain  from  questioning 
whether,  during  the  past  quarter  of  a  century, 
the  work  of  any  class  of  men  has  been  more  pro- 
ductive of  good  for  mankind  than  has  that  of  the 
patient  toiler  in  the  laboratory,  with  his  micro- 
scope and  staining  fluids  and  his  intimate  associa- 
tion with  virulent  disease-producing  germs. 


CHAPTER  IV 

Infections    and   Contagions — Their    Manage- 
ment AND  Control 

"Vague  fear  is  the  mother  of  panic,  and  vague 
terms  are  the  most  potent  generators  of  vague 
fears."  In  beginning  the  study  of  the  infectious 
diseases  it  is  highly  desirable  to  understand  clearly 
what  is  meant  by  the  various  terms  now  employed, 
for  a  misunderstanding  of  them  will  cause  unneces- 
sary fear  and  apprehension,  and  lead  to  the  adop- 
tion of  erroneous  methods  of  management.  Radi- 
cal changes  have  occurred  in  the  application 
of  various  terms  during  the  past  twenty  years. 
The  older  nomenclature,  in  the  light  of  present 
knowledge,  leads  to  confusion  and  misunder- 
standing. 

Diseases  caused  by  micro-organisms  are  now 
known  as  infectious  diseases,  and  the  process  by 
which  they  are  transmitted  is  known  as  infection. 
The  term  refers  to  the  cause  of  disease,  and  not 
to  its  mode  of  transmission.  Hence,  infection  and 
contagion  are  not  synonymous  terms.     Infectious 

43 


44  HOV/   TO    KEEP   WELL 

diseases  may  be  either  transmissible  or  non- 
transmissible.  Not  all  diseases  produced  by  germs 
can  be  transmitted  from  one  individual  to 
another. 

Transmissible  diseases  originate  from  some 
animal  body,  and  are  conveyed  either  directly  or 
indirectly  to  the  person  infected — that  is,  they 
may  be  contagious  or  non-contagious.  By  a 
contagious  disease  is  meant  one  which  is  trans- 
mitted from  an  individual  through  the  air  or  by 
direct  contact.  Scarlet  fever  and  small-pox  are 
examples  of  this  class  of  disease.  A  non-contagious 
transmissible  disease  is  one  which  is  conveyed  not 
by  direct  contact,  but  by  some  intermediate  means 
of  communication.  An  example  of  this  is  tubercu- 
losis, which  is  not  transmitted  by  contact,  but  by 
inhaUng  dust  which  contains  tuberculous  germs 
derived  -from  dried  and  pulverized  sputa  of  some 
consumptive  person.  The  disease  is  thus  trans- 
mitted from  the  first  sufferer  to  the  second  by  indi- 
rect means,  and  not  by  direct  contact,  and  is  there- 
fore not  contagious,  although  it  is  transmissible. 
A  non-transmissible  or  miasmatic  disease  is  one 
derived  from  some  place  or  thing,  and  not  from 
an  individual.  There  is  a  rapidly  growing  doubt 
regarding  the  existence  of  any  true  miasmatic 
disease.     These  various  forms  of  infectious  disease 


INFECTIONS   AND    CONTAGIONS        45 

are    shown    more    clearly    by    the    accompanying 

table. 

-r    r      •         friA  ••-.,(  Contagious. 

Iniectious      Iransmissible  <  ^^       r^     ^     • 
^.  i  Non-Contagious. 

Diseases        ,,       „  •    V 1 

[^  Non- 1  ransmissible. 

The  term  septic  disease  is  sometimes  applied  to 
those  forms  of  infectious  disease  in  which  the 
bacteria  gain  their  entrance  into  the  body  through 
a  wound  or  abrasion  of  the  skin  or  mucous  mem- 
brane. Examples  of  this  class  are  erysipelas, 
and  various  infections  of  surgical  wounds.  By 
the  term  "sepsis"  is  usually  meant  the  infection 
of  a  surgical  wound  or  an  abraded  surface.  From 
this  is  derived  the  expression  "antisepsis,"  which 
means  the  destroying  of  septic  germs,  and  "anti- 
septic," which  is  a  chemical  element  capable  of 
destroying  or  checking  the  growth  of  germs. 
By  "asepsis"  is  meant  the  prevention  of  sepsis, 
or,  in  other  words,  the  exclusion  of  germs  from 
wounds  and  abrasions. 

Certain  other  terms  are  in  frequent  use,  and 
should  be  understood.  A  disease  is  "epidemic" 
when  it  spreads  rapidly  and  attacks  many  persons 
at  the  same  time.  A  disease  is  "endemic"  when 
it  is  constantly  present  in  a  place.  For  example, 
diphtheria  is  endemic  in  all  large  American  cities, 
but    occasionally    becomes    epidemic.     Cholera    is 


46  HOW   TO    KEEP   WELL 

endemic  in  India,  but  periodically  extends  beyond 
its  habitat  in  epidemics.  A  "pandemic  "  is  a  very 
widespread  epidemic.  It  is  a  term  used  to  indi- 
cate that  a  disease  has  spread  over  a  continent 
or  has  become  world-wide,  as  did  influenza  in 
1889. 

The  infectious  diseases  have  certain  features 
in  common.  There  is  a  period  between  the  expo- 
sure and  the  development  of  the  first  symptoms 
known  as  the  period  of  incubation.  During  this 
time  the  bacteria  which  have  entered  the  body  are 
multiplying  and  acquiring  strength  sufficient  for 
the  production  of  symptoms.  This  period  of 
incubation  varies  greatly  in  different  diseases,  and 
even  in  the  same  disease.  The  number  of  germs 
introduced,  their  varying  activity,  and  the  resisting 
power  of  the  individual,  all  have  their  effect  in 
determining  the  time  when  sufficient  poison  is 
generated  to  produce  symptoms. 

Many  infectious  diseases,  particularly  those  of 
the  contagious  type,  are  self-limiting.  They  run 
a  more  or  less  definite  course,  and  end  in  recovery 
within  a  certain  definite  time,  if  the  patient  has 
sufficient  strength  to  combat  them.  They  usually 
begin  with  a  definite  onset  marked  by  decided  and 
characteristic  symptoms.  Of  these,  a  chill  is  the 
most   common,   l)ut   vomiting,    nausea,   headache, 


INFECTIONS   AND    CONTAGIONS        47 

malaise,  and  in  young  children  convulsions,  fre- 
quently occur.  Very  few  diseases  terminate  by 
crisis.  Pneumonia  does  this  more  commonly  than 
does  any  other  disease.  Crisis  consists  in  a  rapid 
fall  of  temperature  and  beginning  improvement. 
It  is  rarely  theatrical.  The  "fever"  of  romance, 
in  which  the  patient  after  a  profound  sleep  awakes 
at  an  hour  exactly  foretold  by  the  physician,  who 
pronounces  the  danger  past,  is  not  seen  in  actual 
practice.  Sudden  changes  for  the  better  fre- 
quently occur,  but  can  rarely  be  foretold  with 
certainty.  As  a  rule,  recovery  from  the  infectious 
diseases  is  gradual,  and  the  serious  symptoms  do 
not  all  subside  at  a  definite  time.  There  is  no 
critical  day  for  each  disease  on  which  it  can  be  said 
that  the  patient,  having  passed  it,  is  out  of  danger. 
That  momentous  question  must  be  decided  for 
each  patient  according  to  the  conditions,  and  not 
because  he  has  passed  a  certain  number  of  days. 
The  medicine  of  the  novel  has  but  little  in  common 
v/ith  that  of  everyday  practice. 

In  endeavouring  to  prevent  the  spread  of  the 
infectious  diseases  a  knowledge  of  their  natural 
history  or  the  course  which  they  naturally  run  is 
necessary.  In  dealing  with  the  contagious  dis- 
eases two  periods  must  be  taken  into  considera-  \j 
tion,   that   of  incubation   and  that   of   contagion. 


48  HOAV   TO    KEEP    WELL 

Upon  these  are  based  the  periods  of  quarantine 
and  of  isolation.  The  incubation  period  has 
already  been  defined  as  the  time  between  exposure 
and  the  appearance  of  symptoms.  The  quaran- 
tine period  is  the  time  during  which  those  who 
have  been  exposed  to  a  disease  should  be  isolated 
to  prevent  the  exposure  of  others.  It  is  equal, 
therefore,  to  the  longest  possible  period  of  incu- 
bation. Quarantine  may  be  either  public  or  pri- 
vate. A  child  in  quarantine  for  scarlet  fever, 
for  example,  is  not  necessarily  confined  to  a  single 
room,  but  is  prevented  from  mingling  with  other 
children  who  have  not  had  the  disease,  until  the 
period  of  incubation  is  passed.  As  the  period 
of  incubation  is  variable,  the  quarantine  period 
must  be  placed  at  the  longest  possible  or,  at 
least,  the  longest  probable  time  of  incubation. 
Thus,  if  the  period  of  incubation  for  scarlet 
fever  varies  from  one  day  to  seven  days,  the 
child  should  be  quarantined  for  at  least  seven 
days. 

The  contagious  period  is  the  time  during  which 
the  disease  may  be  transmitted  by  the  patient 
to  others.  It  is,  therefore,  the  time  during  which 
he  should  he  isolated.  These  various  periods  of 
the  more  common  diseases  are  shown  in  the  accom- 
panying   table.     It    should    be    understood    that 


INFECTIONS    AND    CONTAGIONS        49 


averages   represent    probabilities,    while    extremes 
indicate  possibilities. 


Disease 

Incubation  Period 

Quar- 
antine 
Period 
(days) 

Avr'ge 
(days) 

Extremes 
(days) 

Diphtheria 

Scarlet  Fever 

Cholera 

Influenza 
Typhus  Fever 
Typhoid  Fever 

Measles 

Whooping-cough 

Smallpox 

German  Measles 

Chicken  Pox 

Mumps 

2 

2 
2 

3 

7 

12 

12 

I  2 

I  2 
14 

14 
iS 

^  to  6 
'A  to  7 

I  to   lO 

I  to  5 

5  to  12 

8  to  18 

9  to  16 
7  to  16 
y  to  I  6 

6  to  18 
I  2  to  1  6 
14  to  21 

6 

,      7 
10 

5 
12 
1 8 

r6 

16 

16 
18 
16 
21 

From  earliest  symptoms 
until  germs  have  disap- 
peared- Two  weeks  after 
membrane  is  gone. 

From  appearance  of  rash 
till  desquamation  has 
ceased,  usually  six  weeks. 

From  onset  till  one  week 
after  the  diarrhea  has 
ceased. 

From  onset  to  complete 
convalescence. 

From  onset  to  complete 
convalescence. 

From  onset  to  two  weeks 
after  fever  is  gone,  usual- 
ly six  weeks. 

From  first  catarrhal  symp- 
toms to  convalescence, 
twenty-four  days. 

From  first  catarrhal  symp- 
tomstocessation  of  cough, 
often  three  months. 

From  onset  until  last  crust 
has  fallen,  usually  six 
weeks. 

From  two  days  before  rash 
till  symptoms  are  gone, 
often  two  weeks. 

From  onset  until  last  crust 
has    fallen,  usually   four- 

'    teen  days. 

From  one  day  before  to  ten 
days  after  swelling,  usual- 
ly three  weeks. 

The  contagious  diseases  are  spread  more  widely 
through  failure  to  enforce  isolation  than  by  any 
other  means.  This  may  result  from  failure  to 
recognize  their  presence,  for  sometimes  they  are 
insidious  in  their  onset,  notably  diphtheria  and 
typhoid    fever.     Others,    like    measles,    are    often 


50  HOW   TO    KEEP    WELL 

mistaken  during  the  first  few  days  for  some  other 
disease.  Every  doubtful  or  suspicious  case  should 
be  isolated  until  its  nature  can  be  determined. 
Physicians  are  sometimes  blamed  for  causing 
unnecessary  alarm  in  expressing  fears  as  to  the 
nature  of  a  disease.  Reasonable  people,  however, 
do  not  object  to  such  caution,  and  prefer  the  trouble 
caused  by  temporary  isolation  to  the  dangers  and 
troubles  which  may  result  from  the  exposure  of 
other  children.  It  should  not  be  forgotten  that  a 
mild  case  of  any  infectious  disease  in  one  indi- 
vidual is  capable  of  causing  the  most  virulent  type 
in  another. 

The  question  of  school  attendance  usually 
arises  upon  releasing  a  cliild  from  isolation. 
Schools  are  the  most  potent  means  of  disseminat- 
ing the  infectious  diseases.  It  is  a  serious  matter 
to  allow  a  child,  regarding  whom  there  is  the 
slightest  suspicion,  to  go  to  school.  Illness  and 
death  may  follow  an  error  of  this  kind.  The 
system  of  school  inspection  now  in  force  in  most  of 
our  larger  cities  cannot  be  too  highly  commended. 
Its  value  and  importance  are  shown  by  the  fact  that 
on  the  first  65  days  of  inspection  when  the  system 
was  inaugurated  in  New  York,  the  following  cases 
of  diseases  were  discovered:  whooping-cough,  26; 
scarlet  fever,  32;  measles,  88;  mumps,  117;  diph- 


INFECTIONS   AND    CONTAGIONS        51 

theria,  167;  contagious  eye  disease,  702;  parasitic 
diseases  of  the  head,.  2,627.  After  the  first  few- 
months,  the  diseases  discovered  were  less  numer- 
ous, showing  that  parents  had  learned  that  children 
sent  to  school  ill  would  be  sent  home,  and  had 
become  more  careful.  This  latter  result  is  one  of 
the  most  important  effects  of  school  inspection. 
A  potent  means  of  disseminating  contagious 
disease  is  the  arrangement  of  the  coat -rooms  of 
many  schools.  The  outer  clothing  of  the  children, 
some  of  whom  may  have  come  from  families  in 
which  disease  exists,  is  hung  closely  together, 
sometimes  layer  upon  layer  upon  the  same  hook. 
The  rooms  are  frequently  small  and  ill- ventilated, 
and  sometimes  mere  unlighted  and  overheated 
closets,  where  every  facility  is  offered  for  the  dis- 
semination of  bacteria.  The  coat-rooms  of  schools 
should  be  large  and  well  ventilated,  with  room 
sufficient  for  hanging  each  child's  clothes  separately. 
The  advisability  of  closing  schools  in  the  event 
of  a  serious  epidemic  must  be  settled  differently 
in  different  communities.  In  the  country  and  in 
small  towns,  where  the  children  will  be  separated 
from  one  another  when  at  home,  their  closure  may 
be  an  important  measure  of  prevention.  More- 
over, in  such  a  community  illness  in  a  family  is 
at  once  known  and  contagion  is  guarded  against. 


52  HOW   TO    KEEP   WELL 

In  large  cities,  on  the  other  hand,  the  conditions 
are  quite  different,  particularly  in  the  crowded 
tenement  regions.  Here  the  children  cannot 
and  will  not  be  confined  to  their  homes,  but  will 
mingle  with  one  another  all  day  long.  Closing  the 
schools  will  not  prevent  it.  In  addition  to  this, 
the  daily  inspection  of  the  children  in  school  is  a 
great  safeguard  against  the  spread  of  disease. 

The  selection  of  the  sick-room  for  contagious 
diseases  is  of  much  importance.  In  small  houses 
and  city  flats  there  is  but  little  choice.  Where 
selection  is  possible,  the  room  should  be  chosen 
which  can  be  most  readily  isolated  and  will  at  the 
same  time  be  convenient  and  habitable.  Six 
weeks'  confinement  to  a  single  room,  as  in  scarlet 
fever,  is  a  trying  ordeal,  and  isolation  during  the 
last  days  of  the  period  can  be  more  strictly  enforced 
if  the  room  is  cheerful  and  comfortable.  While  a 
room  at  the  top  of  the  house  is  for  some  reasons 
the  most  desirable,  one  on  the  floor  below  should 
be  selected  should  there  be  no  bathroom  on  the 
top  floor.  The  passing  to  and  fro  to  the  bathroom 
will  frequently  undo  all  the  other  effects  of  isola- 
tion, not  to  speak  of  the  additional  labour 
involved.  A  most  satisfactory  arrangement  is  a 
back  room  on  an  upper  floor  opening  into  a 
bathroom,  the  latter   having   also   a   second   door 


INFECTIONS    AND    CONTAGIONS        53 

into  the  hall.  Two  doors  thus  intervene  between 
the  hall  and  sick-room.  By  placing  a  small  gas- 
stove  in  the  bathroom  much  labour  is  saved 
and  isolation  can  be  made  complete.  When 
possible,  two  rooms  or  a  whole  floor  should  be 
utilized. 

Cracks  and  keyholes  of  unused  doors  should  be 
sealed  with  strips  of  paper  as  for  fumigating.  The 
hanging  of  dampened  sheets  before  the  door  is  a 
measure  of  some  practical  value.  It  is  not  to  be 
supposed  that  they  can  disinfect  the  air  or  destroy 
the  germs,  but  they  do  prevent  currents  of  air 
when  the  doors  are  opened,  and  are  a  constant 
reminder  of  the  necessity  of  care.  The  prepara- 
tion of  one  room  for  a  sick-room  in  a  house,  espe- 
cially where  there  are  children,  is  a  wise  measure. 
Such  a  room  is  not  infrequently  found  in  modern 
houses,  and  should  be  more  common.  In  building 
a  new  house,  a  hospital  room  should  always  be 
arranged  for.  It  may  be  made  as  cheerful  and  as 
available  for  ordinary  use  as  any  other  room.  The 
walls  and  ceilings  are  painted  or  covered  with 
washable  paper.  The  floor  is  polished  and  covered 
with  rugs  instead  of  a  carpet.  The  hangings  are 
easily  removable,  and  there  is  no  upholstered  fur- 
niture. The  furniture  is  of  polished  wood  or 
white  enamel,  and  is  made  without  carving  or  deep 


54  HOW   TO    KEEP   WELL 

grooves.  A  room  thus  arranged  can  be  quickly 
put  into  commission  as  a  sick-room  and  will  greatly 
simplify  the  question  of  prevention.    ^ 

That  isolation  may  be  complete,  it  is  necessary 
that  the  attendant  be  isolated  with  the  patient. 
The  importance  of  a  competent  and  experienced 
nurse  is  very  great.  Important  measures  of 
prevention  are  frequently  overlooked  by  those 
who  have  not  had  previous  experience.  Certain 
measures  are  sometimes  rigidly  enforced,  while 
others  of  equal  importance  are  neglected.  The 
disease  may  thus  be  spread  by  leaving  a  single 
loophole  unguarded.  An  experienced  nurse 
will  avoid  many  errors  which  the  most  con- 
scientious person  without  such  experience  may 
make. 

The  ease  of  preventing  the  spread  of  a  con- 
tagious disease  is  greatly  augmented  if  there  can 
be  a  third  person  to  act  as  an  intermediary  between 
the  nurse  and  the  person  who  has  the  care  of  the 
other  children.  To  this  person  may  be  assigned 
the  duty  of  carrying  the  food  and  various  articles 
required  by  the  nurse,  carrying  away  the  soiled 
clothing,  and  performing  the  numerous  offices 
outside  the  sick-room.  She  thus  comes  into 
close  contact  with  neither  the  sick  nor  the  well. 
In  the  houses  of  the  well-to-do,  where  nurses  are 


INFECTIONS   AND    CONTAGIONS        55 

employed,  a  trusted  servant  may  perform  this 
office.  It  is  a  hardship  for  the  mother  to  make 
a  choice  between  the  invahd  and  the  other  children, 
particularly  if  they  are  small,  but  the  necessity 
of  doing  so  is  undoubted. 

Every  person  who  enters  a  room  in  which  there 
is  a  patient  ill  with  one  of  the  more  serious  con- 
tagious diseases,  particularly  diphtheria  and  scarlet  ' 
fever,  should  wear  a -gown  or  some  loosely  fitting 
outer  garment,  which  can  be  easily  removed 
upon  leaving  the  room.  Such  a  gown  can  be  made 
very  cheaply  of  cotton  cloth.  It  should  be  made 
to  button  closely  about  the  neck  and  wrists,  and 
should  be  long  enough  to  reach  the  feet.  It  should 
be  put  on  before  entering  the  sick-room,  and  should 
be  hung  up  in  the  bathroom  or  other  suitable 
place  upon  leaving.  A  cap  to  protect  the  hair  is 
desirable,  but  not  as  necessary  as  the  gown.  By 
observing  this  precaution,  a  father  may  visit  the 
child  without  the  danger  of  conveying  the  dis- 
ease to  others.  Attending  physicians  should 
wear  a  gown  during  every  visit  to  diphtheria  and 
scarlet  fever  cases,  and  should  thoroughly  disin- 
fect the  hands  and  face  upon  leaving  the  patient. 

The  use  of  antiseptics  has  been  rendered  much 
more  exact  as  our  knowledge  of  the  action  of 
germs   has   become   more   exact.     We   know   that 


Sp  HOW   TO    KEEP   WELL 

the  infective  principle  is  not  a  miasma,  vapour, 
or  intangible  gas,  but  a  germ  which  must  be  killed 
to  be  rendered  harmless.  It  is  impossible  to  fill 
the  air  of  a  room  with  any  vapour  of  sufficient 
strength  to  kill  these  germs,  which  are  very  tena- 
cious of  life,  without  also  killing  or  injuring  the 
human  occupants.  It  is  utterly  useless  to  attempt 
to  prevent  contagion  by  placing  dishes  of  anti- 
septics in  a  room.  Such  methods  should  be 
avoided,  as  the}"  tend  to  engender  a  false  feeling 
of  security,  which  leads  to  the  neglect  of  more 
important  measures. 

The  chief  means  of  obtaining  an  aseptic  con- 
dition is  cleanness — complete,  scrupulous,  per- 
sistent. This  involves  the  care  of  the  patient,  his 
bedding,  clothing,  room,  and  all  that  is  about  him. 
It  is  of  particular  importance  in  diseases  like 
scarlet  fever,  diphtheria,  and  typhoid,  in  which 
the  infective  germs  are  contained  in  the  secretion 
of  the  throat  and  nose  or  are  thrown  off  by  the 
skin  and  bowels. 

As  it  is  not  always  possible  to  prevent  bacteria 
escaping  from  a  person  ill  with  a  contagious 
disease,  nor  to  prevent  their  being  disseminated 
about  rooms  and  buildings,  the  use  of  antisep- 
tics is  sometimes  required.  One  of  the  best 
chemical  antiseptics  is  a  solution  of  the  bichloride 


INFFXTIONS   AND    CONTAGIONS        57 

of  mercury.  This  msiy  be  made  by  dissolving 
a  bichloride  tablet,  commonly  known  as  an  anti- 
septic tablet,  in  a  pint  of  water,  which  makes  a 
solution  of  I  to  1,000,  which  means  one  part  of 
the  chemical  in  1,000  parts  of  water.  If  a  solution 
of  I  to  4,000  is  required,  the  tablet  should  be 
dissolved  in  four  pints  of  water.  Bichloride  solu- 
tions are  odourless  and  do  not  stain.  They  change 
the  colour  erf  some  fabrics,  and  corrode  metals. 
They  should  always  be  made  in  porcelain  vessels, 
and  should  not  be  used  for  instruments  or  other 
metallic  substances.  The  standard  solution  of 
I  to  1,000  may  also  be  made  by  dissolving  one 
drachm  of  bichloride  of  mercury  and  one  ounce 
of  common  salt  in  one  gallon  of  water.  This 
solution,  made  either  by  the  above  formula  or  by 
the  use  of  an  antiseptic  tablet  in  a  pint  of  water, 
will  be  known  through  this  book  as  the  bichloride 
solution.  As  this  solution  is  corrosive  and  very 
poisonous,  but  at  the  same  time  colourless  and 
odourless,  it  is  especially  dangerous  for  household 
use.  Although  many  accidents  result  from  the 
use  of  carbolic  acid,  it  is,  after  all,  safer  than 
bichloride,  and  should  usually  be  selected  when 
an  active  antiseptic  is  required. 

When   small   amounts   of   carbolic   solution   are 
needed   for   household   purposes,    one    teaspoonful 


58  HOW   TO    KEEP   WELL 

may  be  used  in  a  pint  of  water.  The  solution 
should  always  be  made  in  a  pitcher  or  basin  and 
thoroughly  stirred.  When  a  larger  amount  of 
solution  is  required,  it  may  be  made  by  dissolving 
six  ounces  of  carbolic  acid  in  a  gallon  of  water. 
This  will  be  known  hereafter  as  the  carbolic  solution. 
Such  a  solution  does  not  corrode  metals  nor  destroy 
cloth  or  other  fabrics.  It  is  objectionable  because 
of  its  odour  and  poisonous  qualities.  The  refined 
carbolic  acid  should  be  used,  as  the  crude 
drug  has  a  deep  colour  and  bad  odour  and  is  less 
effective. 

For  various  conditions  requiring  disinfection 
these  solutions  may  be  used  as  follows: 

For  the  hands  and  person,  the  carbolic  solution 
in  one-half  or  one-third  strength. 

For  clothing,  towels,  and  bedding,  the  carbolic 
solution  in  full  strength  for  one  hour,  after  which 
they  should  be  boiled. 

For  closets,  drains  and  sinks,  either  solution  in 
full   strength. 

All  discharges  from  the  mouth,  nose,  bladder, 
and  bowels  should  be  received  in  glass  or  porcelain 
vessels.  Either  solution  should  then  be  added  in 
full  strength  and  at  least  twice  the  volume  of  the 
»  discharge.  After  standing  for  one  hour,  the  whole 
may  be  thrown  into  the  closet. 


INFECTIONS   AND    CONTAGIONS        59 

For  sputa  cups,  full  strength  carbolic  solution 
should  be  used. 

Certain  dishes  should  be  reserved  for  the  sole 
use  of  the  patient.  They  should  be  disinfected 
with  full-strength  carbolic  solution  and  then 
boiled  and  rinsed.  The  remains  of  meals  should 
be  burned. 

When  the  patient  has  recovered,  the  entire  body 
should  be  bathed  and  the  hair  washed  with  hot 
water  and  soap.  He  should  then  be  dressed  in 
clean  clothes  (which  have  not  been  in  the  room 
during  his  sickness)   and  removed  from  the  room. 

The  bodies  of  those  who  have  died  from  con- 
tagious diseases  should  be  wrapped  in  clothes 
saturated  with  either  solution,  preferably  the 
bichloride,   in   full   strength. 

All  these  antiseptics  in  strong  solution  are  more 
or  less  irritating  to  the  skin.  For  use  about  the 
eyes  and  various  other  places  a  saturated  solution 
(as  much  as  will  dissolve)  of  boric  acid  is  largely 
used.  Boracic  acid  and  boric  acid  are  two  names 
for  the  same  substance.  It  is  a  mild  antiseptic, 
and  is  not  poisonous  nor  irritating  to  the  skin 
and  mucous  membranes. 

It  should  not  be  forgotten  that  prolonged  boiling 
is  one  of  the  best  antiseptic  measures  at  our  com- 
mand.    Hence,  towels,  handkerchiefs,  and  all  kinds 


6o  HOW   TO    KEEP   WELL 

of  articles  of  clothing  and  bedding  which  can  be 
boiled  or  steamed,  may  be  thus  sterilized.  Hand- 
kerchiefs and  towels  should  be  used  about  con- 
tagious patients  as  little  as  possible.  In  their 
place,  pieces  of  old  cloth  or  squares  of  cheese-cloth 
should  be  used.  They  can  be  burned,  thus  avoid- 
ing the  trouble  and  possible  danger  from  imperfect 
disinfection.  If  they  cannot  be  at  once  burned, 
they  should  be  dropped  into  one  of  the  full-strength 
solutions.  If  the  floor  of  the  sick-room  be  bare, 
it  should  be  washed  daily  with  the  solution  of 
bichloride  in  half  strength.  If  carpeted,  the 
carpet  should  be  brushed  over  daily  with  the  same 
solution. 

At  the  termination  of  such  diseases  as  diphtheria, 
scarlet  fever,  and  smallpox,  all  toys  and  books 
should  be  destroyed.  Books  are  particularly 
dangerous,  for  they  cannot  be  adequately  disin- 
fected. The  room  should  be  washed — floors,  walls, 
ceiling — with  a  full-strength  bichloride  solution, 
and  the  furniture  should  be  wiped  with  the  same 
antiseptic.  Carpets,  upholstery,  hangings,  bed- 
ding, and  mattresses  should,  if  possible,  be  disin- 
fected with  steam.  When  this  is  impossible,  they 
should  be  wiped  thoroughly  with  cloths  dampened 
in  the  bichloride  solution  and  then  fumigated. 
After  this  they  should  be  hung  for  days  in  the  open 


INFECTIONS   AND    CONTAGIONS        6i 

air  and  sunlight.  As  it  is  difficult  to  certainly 
disinfect  articles  of  this  character  except  by  steam, 
all  those  of  lesser  value  should  be  sacrificed. 

Before  the  sick-room  is  occupied  it  should  be 
thoroughly  fumigated.  Fumigation  with  sulphur, 
as  it  is  ordinarily  done,  is  ineffective,  owing  to  the 
small  amount  of  sulphur  used  and  the  dryness  of 
the  atmosphere.  The  various  objects  in  the  room 
should  be  dampened,  and  steam  should  be  gener- 
ated in  it  if  possible.  Three  pounds  of  sulphur 
are  necessary  for  each  i,ooo  cubic  feet  of  air  space. 
The  sulphur  is  best  used  in  the  form  of  fumigating 
candles,  which  may  be  found  in  every  drug  store. 
It  is  best  to  place  each  candle  in  a  shallow  basin  of 
water  to  avoid  danger  of  fire.  The  room  should 
be  sealed  by  placing  strips  of  paper  over  all  cracks 
and  keyholes.  It  should  be  kept  closed  for  at  least 
six  hours  after  the  sulphur  is  lighted,  and  should  be 
thoroughly  aired  before  it  is  again  occupied. 

Formaldehyde  gas  is  superior  to  sulphur  for 
room  disinfection.  It  is  commonly  generated  from 
formalin,  which  is  a  solution  of  formaldehyde  in 
water.  For  this  purpose  several  generators  have 
been  devised.  Not  less  than  six  ounces  of  formalin 
should  be  used  for  each  i  ,000  cubic  feet  of  space, 
and  infected  articles  should  be  exposed  to  its  action 
for    not    less    than    four    hours.     Formaldehyde 


62  HOW   TO    KEEP    WELL 

burns  easily,  and  may  be  set  on  fire  by  an  open 
flame.  It  is  an  excellent  deodorizer  as  well  as  dis- 
infectant. The  necessary  apparatus  is  now  in  the 
hands  of  most  boards  of  health,  and  a  small  gener- 
ator sufficient  for  the  disinfection  of  rooms  of 
ordinary  size  can  be  obtained  at  not  large  expense. 
In  the  absence  of  a  generator,  the  formalin  may 
be  evaporated  from  the  sheets  suspended  in  the 
room.  It  IS  very  irritating,  and  must  be  handled 
with  care. 


CHAPTER  V 

The  Infectious  Diseases 
tuberculosis 

Tuberculosis  is  characterized  by  the  forma- 
tion of  small  nodules  (tubercles)  in  various  tissues 
of  the  body.  These  tubercles  increase  in  size 
and  undergo  one  of  two  changes.  They  either 
soften  and  undergo  a  peculiar  kind  of  degenera- 
tion, which  renders  them  destructive  and  dangerous, 
or  they  harden  and  shrink  and  become  harmless. 
There  is  not  a  tissue  of  the  body  which  may  not 
become  tuberculous.  Tuberculosis  is  one  of  the 
most  protean  of  diseases.  In  the  lungs  it  becomes 
phthisis  or  consumption;  in  the  brain  it  causes 
one  form  of  meningitis.  In  the  spinal  column 
it  produces  Pott's  disease,  with  the  resulting 
deformities  of  the  hunchback.  In  the  joints  it 
appears  as  hip  disease  or  other  joint  disease; 
upon  the  skin  as  lupus;  in  the  glands  as  scrofula. 
It  may  invade  the  liver,  bowels,  kidney,  throat, 
and  bones — no  tissue   is  exempt  from  its   attacks. 

Tuberculosis  is  world-wide  in  its  distribution. 
It  is   found  in   every   country   and  in   every   zone 

63 


64  HOW   TO    KEEP   WELL 

from  the  arctic  to  the  torrid.  It  is  at  present 
the  greatest  scourge  among  diseases,  and  is  prop- 
erly placed  first  among  destroyers  of  human  life. 
One-seventh  of  all  deaths  are  caused  by  it.  In  the 
United  States  about  150,000  die  annually  from 
tuberculosis  in  its  various  forms.  In  the  larger 
cities  it  causes  more  deaths  than  do  scarlet  fever, 
diphtheria,  typhoid  fever,  and  diarrheal  diseases 
combined.  It  is,  however,  diminishing  rapidly, 
and  the  death  rate  is  believed  to  be  at  least  one- 
third  lower  than  it  was  twenty  years  ago.  In 
Massachusetts  the  rate  fell  from  42  in  1853  to  21.8 
in  1895.  The  reduction  in  the  mortality  from 
tuberculosis  in  New  York  City  since  1886  has  been 
over  forty  per  cent.,  which  means  a  decrease  of 
more  tlian  6,000  deaths  annually  in  the  greater 
city.  But  even  yet  it  causes  almost  one-third  of 
all  deaths  between  fifteen  and  forty-five. 

It  occurs  not  only  in  man,  but  also  in  some  of 
the  animals  upon  which  he  is  dependent,  especially 
the  bovine  species.  It  is  a  significant  fact  that 
animals  that  do  not  have  tuberculosis  in  their 
native  state  sometimes  become  subject  to  it  in 
captivity.  It  is  particularly  prevalent  in  those 
portions  of  large  cities  where  people  are  crowded 
together  to  such  an  extent  as  to  materially  lower 
their  vitaHty.     In  New  York  City  its  occurrence 


THE    INFECTIOUS    DISEASES  65 

a  few  years  ago,  per  100,000  population,  among 
different  nationalities,  was  as  follows:  Irish,  645; 
Colored,  531;  German,  328;  American,  205; 
Polish  Jews,  76.  The  peculiar  immunity  shown 
by  the  Jews  has  been  observed  in  all  lands. 

The  immediate  or  exciting  cause  of  tuberculosis 
is  the  bacillus  tuberculosis.  It  is  a  parasitic  germ 
in  the  strictest  sense,  as  it  grows  only  in  the  animal 
body.  In  a  dried  state  it  remains  dormant,  and 
may  retain  its  vitality  for  weeks  or  months.  It  is 
extremely  susceptible  to  direct  sunlight,  and  may 
be  killed  by  a  short  exposure.  It  is  killed  in  a 
few  minutes  by  the  temperature  of  boiling  water, 
but  cannot  be  killed  by  freezing.  It  does  not 
thrive  in  dry,  clear  air,  but  remains  alive  for  long 
periods  in  damp,  dark  rooms.  It  has  the  peculiar 
property  of  stimulating  the  cells  of  the  body, 
wherever  it  lodges  and  grows,  to  the  formation 
of  the  little  nodules  known  as  tubercles.  It  is 
in  this  way  that  it  produces  tuberculosis. 

Although  tuberculosis  never  develops  except 
as  the  result  of  infection  by  the  bacilli,  the  predis- 
posing causes  are  important  and  have  a  potent 
effect  upon  the  occurrence  of  the  disease.  Heredi- 
tary tendency  is  an  active  predisposing  cause, 
but  it  should  be  clearly  understood  that  there 
is   no   direct   hereditary  transmission   of  tubercu- 


66  HOW   TO    KEEP   WELL 

losis,  except  in  rare  cases,  during  the  first  few 
months  of  Hfe.  There  is  sometimes,  however,  an 
inherited  susceptibihty  to  tubercular  bacilli.  This 
susceptibility  is  especially  marked  at  certain  ages, 
differing  somewhat  in  different  families.  Having 
passed  this  age  with  safety,  the  tendency  frequently 
seems  to  disappear,  and  the  patient  may  go  on 
in  safety  through  a  long  life.  Susceptibility  is 
always  greater  when  resistance  is  diminished,  as 
from  overwork,  or  after  grip  or  other  disease. 

The  most  common  portals  of  entrance  for 
tubercle  bacilli  are  the  lungs,  the  alimentary  tract, 
and  wounds  of  the  skin.  Of  these,  tlie  lungs  are 
by  far  the  most  commonly  involved.  While  the 
bacilli  may  be  taken  into  the  body  with  the  food, 
such  mode  of  infection  is  infrequent.  Whether 
they  are  transmitted  to  man  from  cattle,  either 
through  milk  or  meat,  is  at  present  a  debated 
question,  but  the  greater  number  of  observers  are 
strongly  of  the  opinion  that  this  may  occur. 
Certain  it  is  that  in  the  vast  majority  of 
cases  the  bacilli  enter  the  body  through  the 
respiratory    passages,    mingled    with    dust. 

The  most  important  source  of  tuberculosis  is 
the  tuberculous  patient.  This  is  particularly  so 
when  the  disease  involves  the  lungs.  The  sputum 
of  such  patients  contains  the  bacilli  in  large  num- 


THE   INFECTIOUS   DISEASES  67 

bers.  If  deposited  in  places  where  it  may  dry 
and  become  pulverized  the  germs  may  readily 
gain  entrance  to  the  lungs  of  others.  The  most 
common  mode  of  infection  is  the  inhalation  of  air 
contaminated  by  dried  and  pulverized  sputa  of 
consumptives. 

The  question  of  the  contagiousness  of  tubercu- 
losis has  been  recently  raised  by  action  of  the 
United  States  emigration  authorities  in  classifying 
it  as  a  contagious  disease.  This  action  is  regarded 
by  most  competent  authorities  as  unfortunate. 
The  disease  cannot  be  contracted  by  simply  coming 
into  contact  with  a  tuberculous  subject.  The 
impression  that  it  is  contagious  can  accomplish  no 
good  in  the  direction  of  prevention,  and  would 
work  grievous  hardships  upon  many  tuberculous 
patients.  With  the  fact  established  that  tubercu- 
losis is  not  directly  contagious,  but  is  commonly 
transmitted  by  sputa,  prevention  is  comparatively 
easy.  A  consumptive  need  be  in  no  respect  a 
source  of  danger  to  his  friends.  Numerous  details 
of  management  must  be  enforced,  but  by  far  the 
most  important  precaution  is  that  consumptives 
should  expectorate  only  into  receptacles  containing 
antiseptic  fluids,  or  upon  something  that  can  be 
destroyed  by  fire.  Prevention  consists  in  the 
proper  disposal  of  the  sputa  of  consumptives,  in 


68  HOW   TO    KEEP   WELL 

surrounding  those  unfortunates  with  abundance  of 
fresh  air  and  sunlight,  and  in  the  destruction  of 
every  tuberculous  animal. 

The  first  step  in  prevention,  therefore,  should  be 
to  inform  the  sufferer  from  tuberculosis  of  the 
nature  of  his  disease.  Objection  is  often  raised 
to  this  course  on  the  ground  that  it  will  add  dis- 
couragement to  the  other  burdens  of  the  illness. 
If  the  information  is  given  in  the  proper  way  this 
need  not  be  the  result.  After  the  first  surprise, 
tuberculous  patients  are  rarely,  if  ever,  made  worse 
by  the  knowledge,  but  go  through  the  slow  progress 
of  the  disease  more  easily,  if  they  know  something 
of  its  true  nature.  It  is  hope  deferred  that  maketh 
the  heart  sick,  and  the  physician  sees  no  more 
pitiful  sight  than  the  tuberculous  patient  con- 
stantly looking  for  the  improvement  which  does 
not  come.  He  often  goes  from  place  to  place,  and 
from  doctor  to  doctor,  and  fails  to  gain  the  relief 
and  comfort  which  a  consistent  plan  of  treatment 
laid  down  by  a  physician  in  possession  of  all  the 
facts  in  the  case  might  give.  But  even  to  save 
the  feelings  of  the  one,  is  it  right  to  deliberately 
risk  the  lives  of  the  many?  Tuberculous 
subjects  should  certainly  be  informed  suf- 
ficiently of  the  nature  of  their  disease  to 
make    them    careful    in    the    carrying    out  of  the 


THE    INFECTIOUS    DISEASES  69 

precautions   necessary  to  prevent  its  transmission 
to  others. 

A  knowledge  of  tuberculosis  and  its  methods  of 
transmission  readily  suggests  methods  of  preven- 
tion. The  first  and  most  important  measure 
should  be  the  care  of  the  sputa,  which  should  be 
received  in  proper  receptacles  or  upon  cloth  which 
can  be  burned.  In  the  house,  such  receptacles 
should  be  of  glass  or  china.  They  should  contain 
a  carbolic  or  bichloride  solution,  and  should  be 
scalded  with  boiling  water  twice  a  day.  The 
greatest  care  should  be  exercised  by  the  patient 
that  none  of  the  sputa  escape  beyond  the  fluid. 
Sputa  cups  made  of  thick  paper  may  be  obtained 
in  most  drug  stores.  They  are  cheap,  and  should 
be  burned  after  being  used.  When  it  is  not  con- 
venient to  use  such  a  receptacle,  the  patient  should 
expectorate  into  old  cloths  or  squares  of  cheese- 
cloth. These  also  should  be  burned.  A  cheap 
and  excellent  substitute  are  the  Japanese  napkins 
of  paper.  Several  sputa  flasks  designed  to  be 
carried  in  the  pocket  have  been  devised.  One  of 
the  best  of  these  is  known  as  the  Knopf  flask, 
and  can  be  obtained  at  instrument  stores.  The 
best  flask,  however,  is  probably  that  known  as 
the  Marine  Hospital  sputa  flask,  made  by  the 
Kny-Scheerer  Company,  of   New  York.     It   does 


70  HOW   TO    KEEP   WELL 

not  spill,  can  be  readily  sterilized,  and,  above 
all,  from  a  practical  point  of  view,  can 
be  used  in  a  handkerchief  without  attracting 
attention. 

Both  the  patient  and  his  friends  should  be 
impressed  with  two  points:  first,  that  he  is  a 
possible  source  of  danger,  and  may  transmit  the 
disease  to  others;  and  second,  that  he  is  not  neces- 
sarily a  source  of  danger  to  any  one.  By  observing 
strictly  certain  not  irksome  precautions,  he  may 
live  in  the  family  with  entire  safety  to  others. 
"The  consumptive  himself,"  says  Cornet,  "is 
almost  harmless,  and  only  becomes  so  through 
bad  habits." 

All  clothing' and  bedding  soiled  by  the  sputa  or 
other  discharges  of  tuberculous  patients  should  be 
at  once  boiled,  and  the  dishes  he  uses  should  be 
thoroughly  scalded  after  each  meal.  Scrupulous 
personal  cleanliness  should  be  strictly  enforced, 
and  kissing  should  be  forbidden.  The  patient 
should  wash  his  hands  frequently,  for  it  is  possible 
that  he  may  convey  the  bacilli  to  the  dishes,  food, 
or  other  articles  which  will  be  used  by  others. 
Where  these  precautions  are  carried  out  there  is  no 
necessity  for  disinfection  of  rooms  and  apartments. 
Where  they  have  not  been  scrupulously  carried 
out,  the  rooms  in  wliich  the  tuberculous  patient 


THE    INFECTIOUS   DISEASES  71 

has  lived  should  be  thoroughly  fumigated  and 
washed  with  antiseptic  solutions. 

The  sanatorium  treatment  of  tuberculosis  has  of 
late  received  much  attention,  both  popular  and 
professional.  There  are  in  every  community, 
particularly  in  cities,  a  large  number  of  tubercular 
subjects  who  are  unable  to  care  properly  for  them- 
selves. Such  individuals  may  very  justly  become 
public  charges,  as  much  for  the  welfare  of  the 
community  as  from  charitable  motives.  Such 
care  of  the  poor  and  ignorant  will  remove  a  fruitful 
source  of  public  danger.  There  is  still  another 
class  of  intelligent  people,  who  would  gladly  carry 
out  every  detail  of  prevention  and  would  be  bene- 
fited by  removal  from  home  to  a  hygienic  region. 
Great  numbers  of  this  class  are  prevented  from 
doing  so  by  financial  reasons.  There  is  urgent 
need  of  sanatoria  where  such  unfortunates  can  go 
at  small  expense.  Under  present  conditions  the 
great  majority  of  tuberculous  subjects  must  not 
only  want  for  proper  care  and  hygienic  surround- 
ings, but  they  must  be  to  a  greater  or  less  degree  a 
menace  to  others  and  foci  for  the  dissemination  of 
disease. 

The  belief  of  former  years  that  consumption  is 
necessarily  a  fatal  disease  is  now  well  known  to  be 
untrue.     Many  recover  even  in  large  cities.     When 


72  HOW   TO    KEEP   WELL 

the  proper  climatic,  hygienic  and  medical  treat- 
ment is  begun  early,  the  possibilities  of  recovery 
are  excellent. 

About  sixty  per  cent,  of  all  the  people  who  die 
in  the  New  York  hospitals  show,  if  autopsy  is 
made,  that  at  some  time  in  their  lives  they  have 
had  tuberculosis.  Only  half  of  this  number 
die  of  it,  however.  The  remainder  recover,  and  in 
most  instances  have  never  known  of  its  existence 
in  their  systems. 

It  should  be  fully  understood  that  there  is  no 
specific  treatment,  and  that  there  is  no  drug, 
antitoxin  or  vapour  known  which  can  in  any  sense 
be  considered  a  cure.  The  Committee  on  the 
Prevention  of  Tuberculosis  of  the  Charity  Organ- 
ization Society  of  New  York  has  recently  spoken 
very  positively  on  the  subject  in  the  following 
resolution:  "There  is  no  specific  medicine  for 
this  disease  known,  and  the  so-called  cures  and 
specifics  and  special  methods  of  treatment  widely 
advertised  in  the  daily  papers  are,  in  the  opinion 
of  the  Committee,  without  special  value,  and  do 
not  at  all  justify  the  extravagant  claims  made  for 
them,  and  serve  chiefly  to  enrich  the  promoters 
at  the  expense  of  the  poor  and  frequently  ignorant 
and  credulous  consumptives.  It  is  the  unanimous 
opinion   of   the  Committee   that   no   cure   can   be 


THE    INFECTIOUS    DISEASES  73 

expected  from  any  kind  of  medicine  or  method 
except  the  regularly  accepted  treatment  which 
relies  mainly  upon  pure  air  and  nourishing  food." 
These  advertised  methods  of  sure  cures  for  con- 
sumption do  great  harm  in  raising  hopes  which  end 
only  in  disappointment  and  in  delaying  the  begin- 
ning of  rational  treatment. 

The  tuberculin  devised  some  years  ago  by  Koch 
failed  to  fulfil  the  hopes  that  were  based  upon  it. 
As  yet  no  antitoxin  has  been  produced,  although 
great  labour  has  been  expended  in  that  direction. 
There  certainly  seems  at  the  present  writing  to  be 
some  hope  that  such  an  element  may  be  obtained 
in  the  not  distant  future  which  will  prove  of  value 
in  the  early  stages.  Owing  to  peculiarities  in  the 
growth  of  the  tubercle  germ,  the  obstacles  in  the 
way  of  securing  an  antitoxin  are  very  great.  The 
Rontgen  treatment  promises  something,  but  its 
use  at  the  best  will  probably  be  limited  to  certain 
special  classes  of  cases.  The  germs  are  deeply 
embedded  in  the  tissues,  beyond  the  reach  of  any 
known  germicide  or  antiseptic. 

The  most  rational  and  successful  treatment  at 
present  available  consists  in  placing  the  tissues 
in  a  favourable  condition  to  combat  the  bacilli. 
This  is  accomplished  by  the  use  of  certain  diet  and 
drugs,  and  by  removing  the  patient  to  the  pure  air 


74  HOW   TO    KEEP   WELL 

and  sunlight  of  the  mountains.  The  outdoor  life 
now  enforced  in  all  sanatoria  is  particularly  impor- 
tant. Along  these  lines  of  treatment  substantial 
advancement  has  been  made,  and  many  lives  are 
to-day  saved  which  twenty  years  ago  would  have 
been  lost. 

TYPHOID     FEVER 

Typhoid  fever  is  a  communicable,  infectious 
disease,  but  is  not  contagious.  It  is  caused  by  the 
bacillus  typhosus,  discovered  by  Eberth  in  1884. 
It  occurs  in  all  countries,  but  is  more  common  in 
those  of  the  temperate  zone.  Although  sporadic 
cases  frequently  develop,  they  do  not  occur  spon- 
taneously, but  are  the  result  of  germs  derived  from 
some  previous  case.  It  is  so  much  more  common 
in  the  fall  that  it  was  formerly  known  as  autumnal 
fever.  In  England  it  is  commonly  called  enteric 
fever.  Although  most  frequent  in  August  and 
early  autumn,  epidemics  as  well  as  sporadic  cases 
may  occur  at  any  time.  Typhoid  fever  normally 
runs  a  course  of  four  weeks,  several  weeks  longer 
being  required  for  convalescence.  Its  chief  local 
manifestation  is  ulceration  of  the  bowels.  In  fatal 
cases  death  results  from  perforation  of  one  of  these 
ulcers,  from  hemorrhage,  from  the  direct  poison 
of  the  disease,  or  from  exhaustion. 

Typhoid    fever   is    one   of   the   most    important 


THE    INFECTIOUS   DISEASES  75 

diseases  of  civil  life,  while  no  other  disease  causes 
such  havoc  among  encamped  armies.  Armies 
upon  the  move  are  little  affected  by  it.  During 
the  Spanish-American  war  there  were  20,738 
cases,  affecting  almost  one-fifth  of  the  encamped 
strength  of  the  American  army.  It  caused  more 
than  eighty-six  per  cent,  of  all  the  deaths  on  the 
American  side  during  the  war.  In  the  German 
army  before  Metz,  31.8  of  the  troops  suffered  from 
the  disease.  In  civil  life  it  is  largely  a  disease  of 
young  adults,  being  most  frequent  between  fifteen 
and  twenty-five  years. 

The  bacillus  of  typhoid  is  a  non-spore-forming 
germ,  developing  outside  the  body  as  well  as  within 
it.  It  is  killed  by  a  temperature  considerably 
below  that  of  boiling  water,  but  resists  freezing. 
It  has  been  found  active  in  ice  after  eighteen  wrecks, 
though  a  majority  of  the  bacilli  die  within  two 
weeks.  It  is  killed  in  a  few  hours  by  direct 
sunlight,  but  resists  drying  for  months.  It  has  been 
found  alive  in  street  dust  after  thirty  days.  It 
will  live  in  ordinary  water  for  fourteen  days,  but 
increases  in  water  very  slightly.  In  milk,  however, 
it  develops  vigorously,  and  has  been  found  alive  in 
sour  milk  after  three  months,  and  for  several  days 
in  butter.  The  disease  is  not  directly  contagious, 
but  in  the  great  majority  of  cases  enters  the  system 


76  HOW   TO    KEEP   WELL 

through  the  digestive  tract.  The  dictum  of 
Ernest  Hart  is  entirely  true:  "You  can  eat 
typhoid  and  you  can  drink  typhoid,  but  you  cannot 
catch  typhoid." 

Among  the  common  modes  of  infection  are 
directly  carrying  the  bacilli  into  the  mouth  by  the 
hands,  and  the  contamination  of  the  food  by 
soiled  hands,  dust,  and  flies.  They  may  also 
be  conveyed  by  clothing  and  dishes.  They  are 
very  tenacious,  and  simple  washing  of  the  hands 
with  soap  and  water  is  not  always  sufficient  to 
remove  them.  A  disinfectant  is  required  for  that 
purpose.  Those  who  are  nursing  typhoid  patients 
cannot  be  too  cautious  in  this  particular,  for  they 
may  readily  infect  not  only  themselves,  but  others. 
The  germs  are  eliminated  by  the  patient  in  the 
discharges  from  the  bowels  and  kidneys,  and 
occasionally,  perhaps,  in  the  saliva. 

The  measures  necessary  for  preventing  the 
transmission  of  the  bacilli  are  numerous  and  must 
be  carried  out  with  precision.  In  scarcely  any 
other  disease,  therefore,  are  the  services  of  a  trained 
nurse  more  desirable.  Many  details  of  manage- 
ment are  learned  by  experience  which  can  be 
taught  in  no  other  way.  The  most  important 
of  these  details  in  the  direction  of  prevention  is 
scrupulous  cleanliness  of  the  patient,  his  bedding 


THE    INFECTIOUS   DISEASES  77 

and  clothing.  As  the  care  of  the  sputa  is  impor- 
tant in  tuberculosis  and  diphtheria,  so  the  care  of 
the  dejecta  is  important  in  typhoid. 

In  civil  life  the  disease  is  transmitted  by 
water  more  commonly  than  by  any  other  means. 
Epidemics  are  frequently  due  to  a  contaminated 
water  supply.  A  single  case  of  the  fever  in  which 
the  discharges  are  allowed  to  drain  into  a  stream 
may  infect  hundreds  of  people  using  the  water  below 
the  point  of  contamination.  Numerous  epidemics 
have  also  resulted  from  infected  milk.  The 
bacilli  are  commonly  introduced  into  the  milk  in 
water  used  for  washing  the  cans  or  dishonestly 
added  by  the  dairyman  or  dealer.  It  has  been 
caused,  also,  by  the  use  of  green  vegetables  and 
salads  which  have  been  fertilized  with  mixtures 
infected  with  typhoid  bacilli.  Oysters  that  have 
been  "fattened"  in  waters  infected  with  typhoid 
evacuations  have  also  caused  the  disease.  It  has 
been  abundantly  proved  that  flies  have  carried 
infection  and  deposited  it  upon  food.  This  is 
one  of  the  most  common  means  of  its  dis- 
semination in  camps.  Cases  of  "walking 
typhoid"  are  fruitful  sources  for  the  dis- 
semination of  the  disease.  They  are  just  as 
dangerous  as  the  more  serious  cases,  and  scatter 
bacilli  broadcast. 


78  HOW   TO   KEEP   WELL 

Typhoid  fever  is  not  a  filth  disease  in  the  sense 
that  it  may  originate  from  filth  alone.  In  fact,  it  is 
not  confined  to  the  poor  and  those  living  in  filthy 
surroundings,  but  has  a  rather  strong  predilection 
for  the  wealthy.  Filth,  sewers,  and  cesspools 
cannot  themselves  cause  the  disease,  but  they 
furnish  conditions  favourable  for  the  preservation 
of  the  bacilli,  and  the  disease  may  thus  originate 
from  them  after  the  patient  that  infected  them 
has  been  forgotten.  A  well  once  infected  may 
be  dangerous  for  months  or  years.  Hence  old 
wells  in  cities  and  villages  are  often  plague  spots. 
Even  the  wells  on  farms  may  be  such,  for  cesspools 
and  the  vaults  of  outhouses  are  often  placed 
in  such  close  proximity  that  the  wells  become 
drainage  points  for  filth,  if  not  actual  disease. 
The  safest  water  supply  for  villages  and  farms 
is  an  artesian  or  driven  well,  or  a  deep  issuing 
spring  that  is  protected  from  contamination.  The 
amount  of  typhoid  caused  every  year  among 
summer  boarders  by  an  infected  water  supply 
is  appalling  and  unnecessary. 

Prevention  of  typhoid  consists  in  the  isolation 
and  strict  cleanliness  of  the  patient,  his  clothing 
and  bedding,  and  the  carrying  out  of  all  the  details 
advised  for  the  care  of  the  diphtlieria  patient. 
Disinfection  of  all   discharges   and   soiled   articles 


THE    INFECTIOUS   DISEASES  79 

with  strong  carbolic  or  bichloride  solutions  should 
be  practised.  In  the  country  the  discharges 
should  then  be  buried  deeply,  at  a  safe  distance 
from  any  well.  The  boiling  of  all  water  not  known 
to  be  beyond  suspicion,  and  the  pasteurizing  of 
milk,  is  necessary.  Notwithstanding  every  pre- 
caution, the  disease  will  sometimes  occur,  and  in 
many  cases  no  clue  to  the  origin  can  ever  be 
found. 

One  of  the  discoveries  of  comparatively  recent 
years  which  has  proved  of  great  value  in  the 
diagnosis  of  typhoid  is  the  peculiar  appearance 
known  as  "Widal's  reaction."  If  a  few  drops  of 
the  blood  of  a  patient  who  is  suffering  from 
typhoid  or  has  recently  had  the  disease  be  applied 
to  typhoid  bacilli,  cultures  of  which  are  kept  in 
laboratories  for  that  purpose,  they  may  be  seen 
under  the  microscope  to  undergo  a  peculiar  and 
characteristic  change.  As  the  diagnosis  of  the 
disease  is  frequently  very  difficult  during  the  first 
week,  this  often  proves  of  great  assistance,  for  the 
reaction  can  sometimes  be  obtained  as  early  as  the 
fourth  or  fifth  day.  It  assists  also  in  determining 
the  nature  of  mild  cases,  for  the  disease  sometimes 
runs  a  mild  and  not  characteristic  course.  As 
these  mild  cases  are  infectious,  their  diagnosis  is 
always  important. 


So  HOW  TO   KEEP   WELL 

DIPHTHERIA 

Diphtheria  is  an  infectious  and  contagious 
disease  characterized  by  the  formation  of  a  false 
membrane  upon  some  mucous  membrane  or 
abraded  surface.  It  commonly  appears  on  the 
tonsils  and  throat,  but  not  infrequently  involves 
the  nasal  passages  and  larynx.  It  is  accompanied 
by  symptoms  of  infection,  with  prostration  and 
heart  weakness.  It  is  extremely  variable  in  its 
severity;  it  may  be  very  mild  or  intensely 
malignant. 

Its  history  is  strange  and  interesting,  for  it  has 
had  periods  of  quiescence  followed  by  periods 
of  virulent  and  widespread  epidemics.  It  was 
described  by  early  Greek  physicians,  and  epidemics 
have  appeared  through  all  the  centuries  of  medi- 
eval and  modern  history.  It  was  prevalent  in 
the  American  colonies,  and  in  1771  Doctor  Bard 
of  New  York  wrote  an  admirable  description  of  it. 
It  then  rapidly  subsided,  and  if  it  appeared  at  all 
in  this  country  for  almost  a  century,  did  so  only  in 
occasional  sporadic  cases.  Suddenly,  in  1857,  it 
appeared  in  the  coast  towns  of  New  England  in 
malignant  form.  It  spread  rapidly  throughout 
the  country,  and  soon  became  one  of  the  most 
formidable  diseases  of  modern  times.  It  has 
entrenched  itself  in   almost  every  large  town    of 


THE    INFECTIOUS   DISEASES  8i 

Europe  and  America,  and  few  even  of  the  most 
remote  localities  have  escaped  its  visits.  In  fact, 
the  epidemics  which  sometimes  occur  in  country- 
districts  are  particularly  severe. 

Diphtheria  is  due  to  the  bacillus  diphthericE, 
which  was  discovered  by  Klebs  in  1883  and  was 
further  described  by  Loffler.  It  is,  therefore, 
commonly  known  as  the  Klebs-LofQer  bacillus. 
It  is  a  facultative  germ,  and  develops  freely  outside 
the  body.  Damp,  dark  places,  with  decomposing 
animal  or  vegetable  matter,  are  admirably  adapted 
for  its  propagation.  A  cesspool  or  sewer  into 
which  a  few  diphtheritic  bacilli  have  been  intro- 
duced may  be  a  focus  of  a  widespread  epidemic 
months  afterward.  Drying  does  not  destroy  their 
vitality,  and  they  are  frequently  conveyed  in  dust. 
They  are  killed  by  heat  below  the  boiling  point,  and 
do  not  form  spores.  Owing  to  the  fact  that  they 
develop  so  freely  outside  of  the  body,  and  are  so 
resistent  to  drying,  it  is  very  difficult  to  eradicate 
them  from  a  locality  into  which  they  have  been 
introduced. 

The  development  of  the  diphtheria  bacilli  in  the 
body  is  unique  among  bacteria.  They  are  not 
found  in  the  blood  or  tissues,  but  only  in  the 
pseud  o -membrane,  particularly  in  the  deeper 
layers.     Here  they  grow  and  generate  their  poison, 


82  HOW   TO    KEEP   WELL 

which  is  absorbed  into  the  system  of  the  patient. 
The  diphtheritic  membrane  is,  so  to  speak,  a 
laboratory  in  which  the  germs  work  and  elaborate 
a  chemical  product  of  extraordinary  virulence. 
As  a  rule,  therefore,  the  more  extensive  the  mem- 
brane the  more  serious  the  disease.  When  it 
invades  the  back  of  the  throat  and  nasal  passages 
it  is  particularly  dangerous,  for  absorption  into  the 
system  from  these  localities  is  very  active. 

It  is  frequently  impossible  to  discover  the  source 
of  the  infection,  for  the  germs  may  be  carried  long 
distances  by  clothing,  or  may  be  inhaled  from  the 
air  where  they  are  least  expected.  The  channels  of 
infection  are  so  numerous,  particularly  in  large 
cities,  that  no  positive  rules  for  avoiding  the 
disease  can  be  given.  One  of  the  most  dangerous 
sources  is  the  occasional  "walking"  case,  with 
whom  any  child  may  come  in  contact.  Strict 
isolation  should  be  enforced,  not  only  of  every 
diphtheritic  patient,  but  of  every  child  suffering 
with  sore  throat,  until  its  character  is  positively 
determined.  The  onset  is  often  insidious,  the 
membrane  being  well  developed  and  the  patient  a 
source  of  infection  before  serious  general  symptoms 
appear.  Schools  are  often  sources  of  infection, 
and  should  be  under  medical  inspection. 

Opinions  regarding  dissemination  of  diphtheria 


THE    INFECTIOUS    DISEASES  8;^ 

have  materially  changed  in  the  last  ten  years. 
There  is  no  evidence  to  show  that  the  bacilli  are 
disseminated  by  water,  and  the  popular  belief  that 
diphtheria  is  spread  by  the  air  from  open  drains 
and  sewers  is,  without  doubt,  erroneous.  Numer- 
ous carefully  conducted  investigations  have  failed 
to  detect  them  in  such  air.  Particles  of  membrane 
coughed  out,  dried,  and  pulverized  may  cause  the 
dissemination  of  dried  but  active  germs,  but  it 
does  not  seem  possible  that  they  can  escape  into 
the  air  from  damp  surfaces,  and  they  have  not  been 
so  found. 

All  secretions  of  the  mouth,  throat,  nose,  ears, 
or  other  localities  invaded  by  diphtheria  are  loaded 
with  bacilli.  These  bacilli,  when  dried,  may  be 
conveyed  to  any  distance  and  through  long  periods 
of  time  by  clothing,  bedding,  towels,  handker- 
chiefs, dishes,  and  every  article  used  about  the 
patient.  The  same  rules  regarding  their  care  and 
disinfection  should  be  enforced  as  has  been  sug- 
gested for  tuberculosis,  but  with  even  greater 
thoroughness ,  for  the  germs  are  more  virulent  than 
are  those  of  tuberculosis. 

A  measure  of  great  utility  in  diagnosis  is  the 
making  of  cultures  from  the  throat  of  suspected 
cases.  A  bit  of  secretion  is  obtained  from  the 
throat  bv  means  of  a  small  swab  and  smeared  on 


84  HOW   TO    KEEP   WELL 

the  surface  of  gelatin  placed  in  a  test  tube.  This 
test  tube  is  then  sent  to  the  laboratory,  where  a 
bacteriologist  in  a  few  hours  determines  whether 
the  bacilli  be  present  or  not.  The  importance  of 
this  knowledge  cannot  be  overestimated.  In  the 
early  stages  the  diagnosis  is  often  difficult,  and 
certainty  as  to  the  character  of  the  disease  is  thus 
quickly  attained.  It  is  one  of  the  most  important 
steps  toward  exactness  taken  by  modern  medicine. 
Of  equally  great  importance  is  the  knowledge 
afforded  by  such  cultures  as  to  when  the  bacilli 
have  disappeared  from  the  throat.  As  long  as  they 
remain  the  child  is  capable  of  transmitting  the 
disease  to  others.  It  has  been  found  that  they  are 
frequently  present  in  a  semi-dormant  state  for 
two  weeks  after  the  membrane  has  disappeared 
and  the  patient  is  apparently  well.  In  rare  cases 
they  have  been  found  to  persist  for  three,  four,  and 
even  six  weeks.  While  it  is  true  that  these  belated 
germs  are  not  always  virulent,  it  would  be  an 
unjustifiable  risk  to  allow  a  child  in  whom  they  are 
present  to  mingle  with  others.  These  facts  demon- 
strate the  difficulty,  of  controlling  diphtheria  and 
tracing  the  source  of  infection.  No  one  can  ever 
be  certain  upon  entering  a  crowded  place  that  some 
one  may  not  have  in  his  throat  active  diphtheria 
germs,   or,  in   fact,  the   germs   of   other   diseases. 


THE    INFECTIOUS   DISEASES  85 

The  attempt  upon  the  part  of  boards  of  health  to 
stop  the  dangerous  habit  of  spitting  m  pubUc 
places  ought  to  receive  the  hearty  support  of  every 
decent  citizen.  Disease  is  often  transmitted  by  food 
which  has  been  contaminated  from  human  sources. 
Little  shops  with  families  living  in  close  proximity 
have  frequently  been  in  this  way  the  unsuspected 
source  of  diphtheria  and  scarlet  fever.  Milk  in  open 
cans  is  particularly  prone  to  absorb  bacteria. 

Study  of  the  modes  of  dissemination  of  diphtheria 
suggests  many  measures  of  prevention.  Every 
detail  of  isolation  and  disinfection  should  be  ob- 
served. All  soiled  clothing,  as  far  as  possible, 
should  be  burned.  While  all  these  measures 
should  be  strictly  enforced,  by  all  means  the  most 
important  and  valuable  method  of  prevention  is 
the  injection  of  small  doses  of  antitoxin.  The 
importance  of  this  cannot  be  too  strongly  insisted 
upon.  The  subject  will  be  considered  in  more 
detail  in  the  chapter  on  antitoxin. 

The  knowledge  that  the  diphtheria  bacilli  are 
found  only  in  the  pseudo-membrane,  which  is 
usually  in  sight  and  accessible  in  the  throat,  leads 
at  first  to  the  thought  that  treatment  and  preven- 
tion must  be  very  simple.  As  a  matter  of  fact, 
however,  the  bacilli  are  deeply  embedded,  and 
soaking  the  membrane  for  an  hour    in    a    much 


86  HOW   TO    KEEP   WELL 

stronger  antiseptic  solution  than  can  be  safely 
used  in  the  throat  fails  to  destroy  them.  The 
antiseptic  treatment,  however,  while  an  improve- 
ment over  older  methods,  is  disappointing. 
Forcible  removal  causes  great  suffering,  and 
sometimes  fatal  shock,  and  hemorrhage,  and 
is  invariably  followed  by  a  recurrence  of  the 
membrane  with  more  severe  symptoms.  All  such 
methods  have  been  superseded  by  antitoxin. 

Mixed  Infectiojis. — A  considerable  portion  of 
cases  of  diphtheria  are  "mixed  infections,"  by 
which  we  mean  that  other  bacteria  are  present, 
as  well  as  the  diphtheritic  bacilli.  These  bacteria 
are  usually  streptococci.  They  cause  many  of 
the  septic  symptoms  so  commonly  seen  in  diph- 
theria, and  explain  in  a  measure  the  variability 
of  the  disease.  When  present  they  add  greatly 
to  the  gravity  of  the  case. 

Pseudo-Diphtheria. — The  Klebs-Loffler  bacillus 
is  not  the  only  germ  capable  of  causing  a  pseudo- 
membrane  to  form  in  the  throat.  Certain  strep- 
tococci also  have  this  power.  The  membranes 
they  form  simulate  very  closely  that  of  true  diph- 
theria, and  can  frequently  be  distinguished  only 
by  bacterial  culture.  It  is  important,  however, 
that  this  distinction  should  be  made.  The  one  is  a 
comparatively  mild  disease,  with  a  low  death  rate. 


THE    INFECTIOUS   DISEASES  87 

The  other  is  grave,  and  is  frequently  malignant, 
with  a  death  rate  appallingly  high.  These  facts 
account  largely  for  the  varying  rate  of  mortality 
reported  in  different  epidemics  and  in  the  practice 
of  different  physicians.  Many  cases  of  false 
diphtheria  have  no  doubt  been  considered  as  true 
diphtheria.  Statistics  based  upon  cases  in  which 
a  bacterial  examination  has  not  been  made  are 
not  now  regarded  as  reliable.  The  diphtheria 
caused  by  germs  other  than  the  Klebs-Loffler 
bacillus  is  known  as  pseudo-diphtheria.  It  is  an 
interesting  fact  that  the  membranous  sore  throat 
which  appears  in  the  first  stage  of  scarlet  fever, 
and  sometimes  of  other  diseases,  is  usually  pseudo- 
diphtheria,  while  throats  of  similar  appearance 
occurring  in  the  late  stages  are  usually  true 
diphtheria.  As  a  complication  of  other  diseases, 
pseudo-diphtheria  may  be  very  serious. 

Membranous  Croup. — True  or  membranous  croup 
should  be  distinguished  from  false  or  spasmodic 
croup.  The  latter  is  that  disease  which  comes  on 
suddenly  about  eleven  o'clock  at  night  with  a  loud 
barking  cough,  and  often  with  marked  S3^mptoms. 
It  subsides  after  a  few  hours,  and  on  the  following 
day  the  child  may  show  but  few  symptoms  beyond 
those  of  a  bronchial  cold.  The  attack  is  frequently 
repeated  on  the  following  night.     True  croup  comes 


88  HOW   TO    KEEP   WELL 

on  insidiously,  and  the  symptoms  are  very  rarely 
urgent    until    many    hours    have    passed.     False 
croup  is  due  to  catarrhal  cold  and  spasm  of  the 
larynx.     True  croup  is   due  in  about   85  cases  in 
100  to  diphtheria.     In  the  remaining  cases  it  is  due 
to  pseudo-diphtheria.     In  either  case  it  is  caused  by 
the  formation  of  a  membrane  in  the  narrow  portion 
of  the  throat  about   the  vocal  cords.     Untreated, 
it  is  one   of  the   most  fatal  diseases  of  childhood, 
the  mortality  being  more   than    90   per  cent.     It 
causes    death    by    direct    mechanical    obstruction. 
The  membrane  may  extend  from  the  tonsils  and 
pharynx,  or  it  may  originate  in  the  larynx.      In  the 
latter  case  the  difficulties  in  early  diagnosis  between 
true  and  false  croup  are  often  great;     The  patient 
with  croup  should  be  isolated,  and  every  precaution 
should  be  taken  as  for  diphtheria,  for  it  usually 
is   diphtheritic,   and   no  skill  ex«ept   that   of   the 
bacteriologist   can   determine   that   it   is   not.      In 
any  case  of  sore  throat,  it  is  a  wise  precaution  to 
isolate  the  patient  until  the  nature  of  the  disease 
has  been  determined.     Throats  apparently    inno- 
cent  at  the   outset    sometimes    show    themselves 
later  to  be  diphtheritic  in  nature.      Every  case  of 
croup  should  be  treated  with  antitoxin    prom.ptly. 
If  urgent   symptoms   develop,   intubation    should 
be  performed  as  advised  in  the  section  on  antitoxin. 


THE    INFECTIOUS   DISEASES  89 

SCARLET    FEVER 

Scarlatina,  or  scarlet  fever,  is  an  acute,  infectious, 
contagious  disease,  typical  cases  of  which  present 
the  following  features:  After  a  period  of  incu- 
bation of  from  two  to  four  da^^s  there  is  a  sudden 
onset  of  sore  throat,  vomiting,  and  fever;  within 
twenty-four  hours  an  eruption  appears  on  the  neck 
and  rapidly  spreads  over  the  body;  it  continues 
for  about  six  days,  when  it  terminates  in  desquama- 
tion, which  continues  for  three  weeks  or  longer. 
The  possible  complications  are  numerous  and 
grave,  and  render  the  disease  one  of  the  most 
serious  of  childhood. 

Scarlet  fever  is  rare  before  one  year  and  is  most 
frequent  between  five  and  eight  years.  After  the 
latter  age  the  susceptibility  diminishes,  and  is 
very  slight  during  adult  life.  That  scarlet  fever 
is  an  infectious  disease  does  not  admit  of  doubt, 
but  the  specific  germ  has  not  yet  been  discovered. 
It  has,  however,  been  fully  demonstrated  that 
streptococci  play  an  important  role  in  the  causa- 
tion of  many  of  the  symptoms.  They  are  the 
cause  of  the  membranous  exudations  in  the  throat, 
the  inflammation  of  the  ears  and  the  glands,  and 
probably  also  cause  the  kidney  involvement, 
pneumonia,  and  joint  inflammations  which  some- 
times occur  as  complications.     These  germs  are  so 


90  HOW   TO   KEEP   WELL 

constant  in  their  presence,  and  so  active  in  the 
causation  of  the  more  serious  symptoms  and  com- 
plications, that  they  are  important  factors  of  the 
disease.  Scarlet  fever  is,  in  fact,  commonly  a 
mixed  infection,  the  more  malignant  and  fatal 
symptoms  being  due  not  so  much  to  the  primary 
as  to  the  secondary  infection.  The  specific  germ 
exists  in  the  blood,  for  inoculation  of  the  serum 
into  susceptible  animals  produces  a  typical  attack 
of  the.  disease.  It  is  also  found  in  the  various 
secretions,  and  in  the  scales  from  the  skin,  as 
shown  by  their  power  to  generate  the  disease. 
Susceptibility  of  the  human  organism  to  scarlet 
fever  is  less  decided  than  it  is  to  measles,  exposure 
being  far  less  frequently  followed  by  illness. 

Scarlet  fever  may  be  contracted  by  direct 
exposure  or  through  intermediate  infection.  The 
chief  source  of  direct  infection  is  the  patient  him- 
self, but  the  area  of  infection  is  limited  to  a  few 
feet.  Hence,  close  contact  is  necessary.  The 
scales  thrown  off  from  the  skin  during  desquama- 
tion are  extremely  infectious.  The  retention  of 
these  scales  by  clothing,  bedding,  and  the  walls  of 
the  room  is  one  of  the  most  common  sources  of 
infection.  The  purulent  discharges  which  fre- 
quently occur  during  the  disease  are  also  infectious. 
Scarlet  fever  is  spread  by  indirect  infection  more 


THE    INFECTIOUS   DISEASES  91 

frequently  than  is  any  other  contagious  disease 
except,  possibly,  diphtheria  and  smallpox.  Its 
micro-organism  is  more  tenacious  of  life  than  is 
that  of  any  other  disease  except  smallpox. 
Hence,  it  may  be  conveyed  to  long  distances  by 
clothing,  carpets,  bedding,  books,  toys,  and  letters. 
It  may  be  conveyed  in  the  fur  of  cats  and  dogs. 
The  transmission  of  scarlet  fever  by  milk  and  other 
articles  of  food  is  undoubted.  There  are  numerous 
authentic  cases  in  which  it  has  been  conveyed  by 
letters  written  by  hands  in  the  stage  of  desquama- 
tion. Epidemics  of  scarlet  fever  usually  spread 
slowly  as  compared  to  those  of  measles. 

The  incubation  period  is  very  short.  While 
in  a  few  apparently  authentic  cases  it  has  been  as 
long  as  ten  days,  it  is  rarely  more  than  six  days,  and 
usually  between  two  and  four.  It  is  occasionally  less 
than  one  day.  While  the  period  of  incubation  is 
short,  the  contagious  period  is  very  long.  In  most 
cases  it  is  not  contagious  until  the  rash  has  made  its 
appearance.  We  have  thus  in  scarlet  fever  a 
distinct  advantage  over  measles,  for  in  the  latter 
disease  the  period  of  contagion  begins  two  or  three 
days  before  the  rash  appears.  Children  are  fre- 
quently seen  who  have  been  in  contact  with  scarlet 
fever  patients  several  hours  after  the  initial  vomit- 
ing  and   have   not    contracted   the    disease.     The 


92  HOW  TO   KEEP   WELL 

infective  power  is  active  when  the  eruption  is  at 
its  height;  it  then  diminishes,  but  increases  again 
during  the  stage  of  desquamation. 

The  patient  is  dangerous  to  others  as  long  as  the 
slightest  desquamation  continues  on  any  portion 
of  the  skin.  The  duration  of  this  period  is  extremely 
variable,  and  a  common  error  consists  in  being 
guided  by  a  fixed  number  of  days.  The  conven- 
tional forty  days  is  only  to  be  regarded  as  approxi- 
mate. It  is  rarely  too  long.  Desquamation  is 
liable  to  persist  in  small  areas  of  the  body  after  it 
has  disappeared  from  other  portions.  It  is  fre- 
quently very  difficult  to  determine  in  such  cases 
whether  we  have  to  deal  with  a  local  patch  of 
scarlatinal  desquamation,  or  with  eczema  brought 
about  by  irritation  the  result  of  over-zealousness 
in  bathing  and  anointing.  These  circumscribed 
areas  are  most  commonly  found  about  the  joints. 
Desquamation  is  liable  to  persist  about  the  finger- 
nails after  it  has  disappeared  from  every  other 
part  of  the  body.  There  can  be  no  more  danger- 
ous place  for  such  persistence,  for  the  scales  are 
liable  to  fall  upon  any  article  handled,  and  they 
may  thus  be  conveyed  to  a  distance.  The  period 
of  isolation  is  long,  and  desquamation  is  not  the 
only  factor  by  which  it  is  to  be  determined.  Puru- 
lent discharges  contain  the  infective  principle  of 


THE    INFECTIOUS    DISEASES  93 

scarlet  fever,  and  no  child  who  is  suffering  from 
such  a  discharge  should  be  allowed  to  mingle 
with  others. 

In  few  other  diseases  are  preventive  measures 
so  productive  of  good  results  as  in  scarlet  fever. 
Although  a  far  more  serious  disease  than  measles, 
its  spread  may  be  more  effectively  controlled. 
No  one  will  allege  that  the  measures  necessary  to 
the  attainment  of  that  end  can  be  carried  out 
without  encountering  difficulties.  They  are  many 
and  complex,  but  are  effective  in  preventing  the 
spread  of  the  disease.  When  we  consider  the 
high  mortality  of  scarlet  fever,  and  the  grave 
sequela  which  are  common  in  those  who  survive, 
we  are  forced  to  feel  that  neglect  of  preventive 
measures  is  little  short  of  criminal.  Certain 
measures  are  sometimes  rigidly  enforced,  while 
others  of  equal  importance  are  neglected.  The 
disease  may  thus  be  spread  by  leaving  a  single 
loophole  unguarded. 

As  the  period  of  incubation  in  scarlet  fever  is 
short  and  somewhat  variable,  every  child  who  is 
known  to  have  been  exposed  should  be  absolutely 
quarantined.  Although  a  feeling  of  security  is 
warranted  after  four  days,  no  person  who  has  been 
exposed  should  be  considered  safe  in  less  than  a 
week.     The    question    of    sending    other    children 


94  HOW   TO    KEEP   WELL 

away  from  home  is  often  a  serious  one.  The 
objection  is  frequently  made  that  they  may  carry 
the  disease  to  other  places,  or  the  parents  are 
unwilling  to  have  them  ill  away  from  home.  The 
decision  must  rest  largely  on  the  time  of 
the  exposure.  If  it  occurred  before  the  appear- 
ance of  the  eruption,  there  is  but  little  danger 
that  the  disease  has  been  contracted.  If 
exposure  occurred  during  the  stage  of  eruption, 
the  probability  of  illness  is  great.  If  the 
patient  is  isolated  soon  after  the  appearance  of 
the  initial  s3^mptoms,  other  children  in  the  family 
are  very  unlikely  to  have  taken  the  disease  from 
him. 

Inunction  of  the  body  with  oil  is  prescribed  by 
many  physicians  throughout  the  entire  course  of 
the  disease.  During  the  stage  of  eruption  it  is 
employed  chiefly  as  a  means  of  treatment.  After 
desquamation  has  begun,  the  object  of  inunction 
is  quite  different.  The  procedure  then  becomes  a 
matter  of  prevention  as  well  as  treatment,  and  the 
most  important  object  is  to  soften  and  remove  the 
scales,  thus  preventing  their  dissemination.  It  is 
the  belief  of  many  that  the  scales  may  be  disin- 
fected by  adding  antiseptics  to  the  oily  substance 
used  for  inunction.  This  seems  somewhat  doubt- 
ful, but  the  addition  of  a  mild  antiseptic  can  do  no 


THE    INFECTIOUS   DISEASES  95 

harm.  Caution  should  be  taken,  however,  that 
neither  the  antiseptic  nor  the  oil  employed  have 
an  unpleasant  odour.  The  appetite  in  this  stage 
is  prone  to  be  poor,  and  a  persistent  disagreeable 
odour  may  increase  this  distaste  for  food  and  render 
the  child  irritable. 

Fumigation  of  the  room  in  which  the  scarlet 
fever  patient  has  lived  is  more  important  than  it 
is  after  most  other  infectious  diseases.  Where  it 
is  possible,  formaldehyde  should  be  used,  and 
carpets,  bedding,  hangings,  and  mattresses  should 
be  disinfected  with  steam.  The  room,  as  well  as 
all  furniture,  should  be  wiped  with  bichloride 
solution  (page  57).  The  room  should  then  be 
kept  open  to  the  air  for  several  days,  and  no  person 
who  has  not  had  the  disease  should  enter  it  for 
many  days  or  weeks.  Particular  care  should  be 
observed  in  the  destruction  of  books  and  toys, 
and  all  fuzzy  and  furry  objects,  for  they  cannot 
be  thoroughly  disinfected.  Caution  should  be 
observed  also  against  packing  away  in  trunks  or 
boxes  possibly  infected  articles.  Thus  excluded 
from  the  air  and  moisture,  the  germs  of  scarlet 
fever  may  retain  their  vitality  for  many  months. 

MEASLES 

Rubeola,  or  measles,  is  an  acute,  infectious,  con- 
tagious  disease,  which  presents,  when  it  pursues 


96  HOW   TO    KEEP   WELL 

a  typical  course,  the  following  characteristics: 
After  an  incubation  of  twelve  days  there  is  a 
gradual  invasion  with  dry  cough,  suffusion  of  the 
eyes,  and  catarrhal  symptoms,  followed  on  the 
fourth  day  by  a  coarse,  blotchy  eruption,  which 
appears  first  on  the  sides  of  the  face  and  neck  and 
slowly  spreads  over  the  body.  This  eruption  con- 
tinues for  about  five  days,  when  it  fades  away  and 
is  followed  by  a  bran-like  desquamation,  which 
is  usually  completed  within  a  week.  It  is  most 
common  during  the  first  ten  years  of  childhood, 
but  is  occasionally  seen  in  adults.  It  is  endemic 
in  most  centres  of  population,  but  at  frequent 
intervals  becomes  epidemic.  It  occurs  at  all 
seasons,  but  is  most  common  during  cold  weather. 

Analogy  leads  to  the  belief  that  measles  is  due 
to  a  specific  micro-organism,  but  it  has  not  yet 
been  isolated.  While  it  must  be  an  extremely 
diffusible  germ,  its  vitality  is  small.  It  is  at  least 
a  fact  that  measles  is  the  most  contagious  of  all 
the  infectious  diseases  except  smallpox.  It  is 
uncommon  under  six  months,  but  above  that  age 
every  child  who  has  not  already  had  it  may  be 
expected  to  contract  it  upon  exposure.  Adults 
are  rather  more  susceptible  to  it  than  to  the  other 
infectious  diseases. 

Measles  is  usually  conveyed  by  direct  contact, 


THE    INFECTIOUS   DISEASES  97 

but  the  area  of  contagion  is  large.  It  is  more 
difficult  to  confine  it  to  a  single  room  than  almost 
any  other  disease.  It  may  be  conveyed  by  cloth- 
ing, but  this  mode  of  diffusion  is  far  less  common 
than  in  scarlet  fever.  Although  intermediate 
contagion  may  occur,  it  is  comparatively  rare. 
It  may  be  thus  transmitted  b}^  a  nurse  or  person 
closely  in  contact  with  a  patient  who  goes  directly 
to  a  child  who  is  not  immune. 

The  infectious  power  of  the  poison  is  quickly 
lost,  which  probably  means  that  the  specific  germ 
dies  soon  when  dried.  Sick-rooms,  therefore, 
soon  become  safe  for  occupancy.  This  may  occur 
in  two  weeks  if  the  room  can  be  freely  open  to  the 
air.  While  it  seems  probable  that  the  contagium 
may  be  conveyed  by  the  breath,  it  is  certain  that 
it  resides  in  the  sputa  and  discharges  from  the 
nose  and  eyes.  If  these  are  dried  and  converted 
into  dust,  they  may  undoubtedly  transmit  the 
disease.  The  desquamation  scales  from  the  body 
are  far  less  potent  to  convey  the  poison  than  are 
those  of  scarlet  fever. 

Measles  is  most  contagious  at  the  height  of  the 
attack,  but  it  begins  to  be  so  from  the  very  first 
appearance  of  the  catarrhal  symptoms,  numerous 
cases  being  recorded  in  which  it  was  transmitted 
four  days  before  the  rash  appeared.     This  accounts 


98  HOW   TO    KEEP    WELL 

largely  for  the  widespread  character  of  the  epi- 
demics. Unless  exposure  is  known,  measles  is 
usually  not  suspected,  for  the  symptoms  are  those 
of  a  catarrhal  cold.  It  is  impossible  in  some  cases, 
even  when  suspicion  has  been  aroused,  to  deter- 
mine the  true  nature  of  the  symptoms  before  the 
end  of  the  fourth  day.  Whenever  it  is  desirable 
that  the  disease  should  not  be  transmitted  to 
others,  children  with  acute  catarrhal  colds  should 
be  isolated  until  the  nature  of  the  attack  can  be 
determined.  Except  in  complicated  cases,  in 
which  the  catarrhal  symptoms  are  prolonged,  the 
period  of  contagion  is  not  more  than  twenty-four 
days. 

While  measles  usually  runs  a  simple  and  uncom- 
plicated course,  complications  occasionally  arise, 
and  are  usually  due  to  the  presence  of  staphy- 
lococci. Streptococci  are,  however,  sometimes 
present,  and  cause  more  serious  trouble  than  the 
first-mentioned  bacteria.  As  their  presence  is 
common  in  hospital  wards,  they  render  measles  a 
disease  much  dreaded  in  hospitals  for  young 
children.  They  give  rise  to  pneumonia,  which  is 
always  a  grave  complication.  Pneumonia  is,  in 
fact,  the  cause  of  death  in  ninety  per  cent,  of 
fatal  cases.  It  is  comparatively  common  in  some 
epidemics,  while  in  others  it  is  not  frequently  seen. 


THE    INFECTIOUS   DISEASES  99 

Death  in  uncomplicated  cases  in  well-to-do  private 
practice  is  rare  in  children  more  than  four  years 
of  age.  The  mortality  in  all  ages  is  probably 
from  four  to  six  per  cent.,  but  between  one  and 
three  years  it  is  often  twenty  per  cent.  During 
the  first  three  months  of  1902  there  were  349 
deaths  in  New  York  City  due  directly  and 
indirectly  to  measles.  This  is  evidence  that  the 
disease  is  not  as  harmless  as  it  is  often  credited 
with  being.     It  should  never  be  neglected. 

The  high  mortality  of  measles  before  three  years 
suggests  the  advisability  of  taking  particular  pre- 
cautions against  the  exposure  of  infants.  Delicate 
children  of  the  so-called  scrofulous  type,  and  those 
with  a  hereditary  tendency  to  tuberculosis,  should 
be  especially  guarded  against  exposure.  In  adults 
tuberculosis  is  not  an  uncommon  sequel  of  measles, 
which  seems  to  have  the  power  of  lighting  up 
some  old  latent  tubercular  focus  which  would  have 
otherwise  lain  dormant,  or  of  rendering  the  patient 
especially  susceptible  to  tubercular  invasion. 
While  measles  is  a  far  less  serious  disease  than 
scarlet  fever,  and  the  great  majority  of  cases 
pursue  a  favourable  course  and  give  no  sequela, 
it  is  a  graver  disease  than  it  is  popularly  credited 
with  being,  and  should  receive  more  attention  than 
it  often  does.     There  are  a  number  of  mild  diseases 


loo  HOW   TO    KEEP   WELL 

which  simulate  it,  and  are  often  mistaken  for  it, 
which  has,  perhaps,  added  to  the  popular  belief 
that  it  is  a  simple  and  unimportant  disease. 

The  prevention  of  measles  demands  the  early 
and  absolute  isolation  of  the  sick.  This  should  be 
continued  for  twenty-four  days,  and  as  much 
longer  as  purulent  discharges  from  the  nose,  ears 
or  eyes  may  continue.  The  period  of  quarantine 
for  children  who  have  been  exposed  should  not 
be  less  than  sixteen  days,  and  twenty  is  preferable. 
The  sick-room  is  less  likely  to  prove  dangerous 
than  the  scarlet  fever  sick-room.  Unless  time  be 
an  element  of  importance,  fumigation  is  not 
required.  Thorough  cleansing  and  ventilation  for 
two  weeks  after  the  patient  has  left  it  is  sufficient 
to  insure  safety.  As  the  infection  of  measles  is 
not  so  persistent  as  that  of  scarlet  fever,  such  pro- 
longed precautions  are  not  necessary,  but  during 
the  height  of  the  disease  the  same  measures  should 
be  adopted. 

GERMAN    MEASLES 

Rubella,  rotheln,  or  German  measles,  is  an 
acute,  contagious,  infectious  disease,  which  simu- 
lates measles  in  some  of  its  appearances.  It 
appears  under  two  general  types,  sometimes  known 
as  the  measles  type  and  the  scarlet  fever  type. 
In  the  first  there  is  a  coarse  rough  red  rash  very 


THE    INFECTIOUS    DISEASES  loi 

similar  to  that  of  measles.  In  the  second  form 
the  rash  is  much  finer  and  simulates  that  of  scarlet 
fever.  It  is  the  belief  of  some  at  the  present  time 
that  this  is  actually  another  disease,  and  they  have 
called  it  the  "fourth  disease."  The  rash,  it  is  cer- 
tain, in  the  two  forms  is  quite  dissimilar,  but  the 
symptoms  are  very  similar.  The  disease  is  mild, 
and  the  death  rate,  if  there  be  any,  is  very  small. 
It  is  contagious,  but  less  so  than  measles.  The 
catarrhal  symptoms  are  mild  and  sometimes  absent, 
and  there  is  frequently  no  cough.  While  no  germ 
has  been  found,  there  is  no  question  that  there  is  a 
specific  germ,  for  the  disease  is  not  a  modified  form 
of  either  scarlet  fever  or  measles.  It  frequently 
occurs  in  children  who  have  had  those  diseases. 
In  other  words,  it  does  not  protect  the  individual 
either  from  scarlet  fever  or  measles. 

The  term  "  German  measles,"  by  which  it  is  so 
commonly  known,  is  an  unfortunate  one,  for  it 
leads  to  much  misunderstanding.  It  is  difficult 
for  many  to  appreciate  that  a  person  who  has  had 
one  kind  of  "measles"  is  just  as  subject  to  another 
kind.  While  there  is  no  question  that  measles 
sometimes  occurs  more  than  once  in  the  same 
individual,  many  second  attacks  are  accounted 
for  on  the  ground  of  error  regarding  the  nature 
of  one  or  the  other  of  them.     It  must  be  said  that 


I02  HOW   TO    KEEP   WELL 

the  differential  diagnosis  be'.ween  German  measles 
and  mild  measles  is  sometimes  very  difficult,  and 
it  is  possible  for  experienced  physicians  to  be  in 
doubt  until  the  attack  has  nearly  or  quite  com- 
pleted its  course. 

This  disease  is  so  mild  that  when  the  diagnosis 
is  undoubted,  methods  of  prevention  are  not,  as  a 
rule,  very  vigorously  enforced.  When  prevention 
is  desirable  the  same  course  should  be  pursued  as 
in  the  management  of  measles.  The  incubation  is 
quite  variable,  ranging  from  six  to  eighteen  days, 
the  more  common  period  being  from  twelve  to  six- 
teen days.  Desquamation  is  very  slight,  and  occurs 
in  fine  scales.  It  rarely  lasts  more  than  three  or 
four  days,  and  can  often  not  be  detected,  par- 
ticularly if  the  skin  has  been  anointed  or  bathed 
daily.  As  German  measles  rarely  occurs  sporadic- 
ally, but  usually  in  epidemics,  it  is  the  course  of 
wisdom  to  regard  every  case  as  perhaps  mild 
scarlet  fever  or  measles  until  its  true  nature  has 
been  absolutely  demonstrated. 

SMALLPOX 

Variola,  or  smallpox,  is  an  acute,  infectious,  and 
very  contagious  disease  characterized  by  an  eruption 
which  passes  through  the  stages  of  papule,  vesicle, 
pustule,  and  crust.  During  the  pustular  stage  the 
whole  surface  of  the  body  is  covered  with  festering 


THE    INFECTIOUS   DISEASES  103 

sores,  and  tlie  disease  is  one  of  the  most  loath- 
some known.  It  is  one  of  the  most  virulent  of 
the  contagious  diseases,  and  those  who  are 
exposed,  if  unprotected  by  vaccination,  are  almost 
invariably  attacked.  Although  contagious  from 
the  very  first  symptom,  it  is  particularly  so  during 
the  convalescent  period,  when  desquamation  is 
active.  The  contagion  is  widely  diffusible  through 
the  air,  and  may  be  conveyed  by  clothing  or  bed- 
ding. It  persists  in  rooms  with  extreme  tenacity. 
It  may  be  conveyed  by  persons  who  have  been 
in  .contact  with  the  sick  or  with  articles  which 
have  been  contaminated  with  the  purulent  dis- 
charges. As  the  specific  germs  are  contained  in 
the  fluid  of  the  sores,  and  persistent  in  the  dried 
scales,  it  is  very  difficult  to  limit  their  diffusion. 
The  scales,  dried  and  converted  into  dust,  may 
disseminate  the  disease  as  scarlet  fever  is  dis- 
seminated. 

In  view  of  these  facts,  it  is  one  of  the  most 
unmanageable  of  diseases  in  localities  where 
numbers  of  the  unvaccinated  may  come  in  con- 
tact with  it.  In  most  cases  it  is  transmitted 
through  the  air.  Simply  breathing  the  air  of  the 
room  in  which  a  smallpox  patient  is  ill,  or  coming 
in  contact  with  such  a  patient  in  the  open  air,  is 
sufficient  exposure  to  cause  the  disease. 


I04  HOW   TO    KEEP   WELL 

Smallpox  has  appeared  in  nearly  every  nation 
of  the  globe,  and  is  of  ancient  date.  The  "great 
plague"  described  by  Galen  was  probably  small- 
pox. Further  facts  regarding  the  disease  will  be 
found  in  the  chapter  on  vaccination. 

One  method  of  prevention  is  so  preeminent 
above  all  others  that  it  must  receive  chief  atten- 
tion. That  method  is  vaccination.  It  is  not  only 
sufhcient  for  preventing  the  occurrence  of  the 
disease  in  the  individual,  but  if  universally  carried 
out  eradicates  it  so  that  it  disappears.  In  view 
of  the  fact,  however,  that  there  is  always  in  this 
country  a  considerable  number  of  individuals 
who  for  one  reason  or  another  have  not  been 
vaccinated,  tlie  most  stringent  methods  of  isola- 
tion and  disinfection  should  be  enforced.  The 
health  authorities  are  entirely  justified  in  forcibly 
removing  smallpox  patients  to  hospitals.  Failure 
to  promptly  notify  the  health  authorities  of  its 
appearance  should  be  punished  by  heavy  penalties. 
Where  the  disease  does  appear,  the  directions 
given  for  the  management  of  scarlet  fever  should 
be  enforced  with  the  greatest  thoroughness,  and 
fumigation  should  be  done  with  more  than  usual 
care.  Every  city  should  have  properly  equipped 
hospitals  for  the  treatment  of  smiallpox,  so 
arranged  that  they  can  be  extended  to  accommo- 


THE    INFECTIOUS   DISEASES         105 

date  the  unusual  numbers  which  may  require 
treatment  during  an  epidemic.  The  complaints 
sometimes  made  because  all  classes  of  patients  are 
treated  together  are  scarcely  warranted.  Public 
authorities  could  not  properly  discriminate  and 
offer  better  conditions  to  one  than  to  another. 
The  proposition  recently  made  in  New  York  to 
build  a  hospital  for  private  patients  by  private 
subscriptions  was  foredoomed  to  failure.  The 
initial  expense  of  constructing  such  a  hospital, 
and  the  continual  expense  of  maintaining  it,  and 
keeping  physicians  and  nurses  ready  at  any  mo- 
ment to  receive  a  patient  during  the  long  inter- 
vals between  epidemics,  would  be  very  grfeat. 
There  are  months  together  in  New  York  City 
when  no  case  is  reported.  People  of  wealth,  who 
have  taken  the  precaution  of  protecting  them- 
selves and  their  families  against  the  disease  by 
the  simple  process  of  vaccination,  can  hardly  be 
expected  to  give  large  sums  of  money  for  the 
benefit  of  those  who  do  not  take  such  precautions. 

CHICKEN-POX 

Varicella,  or  chicken-pox,  is  an  acute,  contagious 
disease,  characterized  by  mild  general  symptoms 
and  an  eruption  of  papulae  and  vesicles.  It  is 
entirely  distinct  from  smallpox,  although  one  of  its 
chief  points  of  importance  is  the  difficulty  occa- 


ro6  HOW   TO    KEEP   WELL 

sionally  experienced  in  distinguishing  it  from  that 
disease  in  its  early  stage.  Its  diagnosis  is  usually, 
however,  very  easy.  It  affects  children  of  all  ages, 
but  particularly  those  under  four  years.  It  is 
very  contagious,  and  few  children  escape  it.  The 
incubation  is  from  twelve  to  sixteen  days.  It  is 
contagious  from  the  onset,  and  continues  so  until 
the  vesicles  are  dried.  Although  clearly  an 
infectious  disease,  its  germ  has  not  l)een  discovered. 
It  is  known  to  lie  in  the  contents  of  the  vesicles, 
for  it  can  be  transmitted  by  inoculation.  The 
disease  is  so  mild  that  preventive  measures  are 
rarely  enforced.  When  such  measures  are  desir- 
able they  are  similar  to  those  advised  for  measles. 
Chicken-pox  rarely  occurs  more  than  once  in  the 
same  individual. 

MUMPS 

Parotitis,  or  mumps,  is  an  acute,  contagious 
disease,  characterized  by  swelling  of  the  parotid 
gland  and  occasionally  of  the  other  salivary  glands, 
and  by  constitutional  symptoms,  which  are  usually 
of  a  mild  type.  Mumps  is  less  common  than  most 
of  the  other  contagious  diseases  of  children,  and 
many  escape  it.  It  is  endemic  in  all  countries, 
but  frequently  occurs  in  local  epideraics.  It  is 
most  frequent  between  five  and  fifteen  years,  and 
is   very   rare    in    infants.     It    is    contagious,    but, 


THE    INFECTIOUS   DISEASES         107 

as  a  rule,  close  contact  is  recjuired.  It  is  rarely 
carried  by  a  third  person  or  by  clothing,  but  this 
mode  of  communication  is  possible.  Suscepti- 
bility of  most  children  to  mumps  is  not  great. 
It  is  contagious  from  the  very  first  symptoms  and 
for  several  days  after  the  swelling  has  subsided, 
but  the  exact  period  of  contagion  cannot  be 
stated  with  certainty. 

Both  bacilli  and  micrococci  have  been  discov- 
ered in  liberal  numbers  in  the  swollen  glands,  but 
it  has  not  been  demonstrated  that  they  are  the 
primary  cause  of  the  disease.  The  period  of  incu- 
bation is  variable,  but  is  most  commonly  from 
seventeen  to  twenty  days.  Prevention  consist:j 
in  isolation  of  the  patient  for  twenty  days  from 
the  appearance  of  the  first  symptoms.  This  is 
the  period  usually  required,  also,  for  quarantine 
when  the  disease  occurs  in  schools  and  institu- 
tions. If  the  room  in  which  the  patient  is  ill  is 
freely  open  to  the  air,  fumigation  and  disinfection 
are  not  required. 

WHOOPING-COUGH 

Pertussis,  or  whooping-cough,  is  a  contagious 
disease  marked  by  catarrhal  symptoms  and  a 
peculiar  and  characteristic  paroxysmal  cough.  It 
is  a  disease  of  early  childhood,  nearly  one-half  of  all 
cases  occurring  during  the  first  two  years  of  life. 


io8  HOW  TO    KEEP   WELL 

While  in  later  childhood  it  is  one  of  the  milder 
diseases,  in  infancy  it  is  serious  and  sometimes 
fatal.  Broncho-pneumonia  and  convulsions  are 
the  chief  complications.  It  cannot  be  said  with 
certainty  that  the  germ  has  been  discovered,  but  it 
seems  probable  that  further  investigations  will 
confirm  the  belief  that  Koplik's  bacillus  is  the 
specific  cause.  The  lungs  appear  to  be  the  seat 
of  invasion,  and  the  catarrhal  stage  which  always 
precedes  the  appearance  of  the  paroxysmal  attacks 
represents  the  period  of  the  growth  and  develop- 
ment of  the  bacilli. 

Whooping-cough  is  very  contagious  from  the 
very  beginning  of  the  catarrhal  stage,  but  it  is 
difficult  to  speak  as  positively  as  to  the  time  when 
it  ceases  to  be  contagious.  It  is  certainly  so 
during  the  entire  spasmodic  stage,  and  probably 
longer.  Isolation  from  other  children  is  often 
necessary  for  twelve  weeks.  A  peculiar  spasmodic 
cough  sometimes  occurs  weeks  after  the  disease 
has  subsided.  It  may  be  brought  on  by  slight 
exposure  to  cold  or  by  choking.  This  cough  is  not 
contagious.  It  may  appear  at  intervals  during 
the  whole  winter  if  the  child  has  whooping-cough 
in  the  fall. 

The  patient  himself  is  usually  the  source  of 
contagion.     The  disease  is  rarely  transmitted  by 


THE    INFECTIOUS   DISEASES         109 

clothing,  by  the  room,  or  by  the  third  person. 
The  latter  is  possible,  however,  should  a  person 
who  is  in  close  contact  with  a  sick  child  go  at  once 
to  another  child  without  a  change  of  clothing. 
While  the  area  of  contagion  is  not  great,  the 
disease  can  be  transmitted  in  the  open  air.  Con- 
tagion is  just  as  active  in  the  interval  as  during  a 
paroxysm,  except,  perhaps,  that  the  germs  may 
be  blown  a  little  greater  distance  from  the  patient. 

The  period  of  incubation  is  somewhat  difficult 
of  determination,  owing  partly  to  the  usually 
insidious  onset  of  the  disease  and  the  difficulty  of 
determining  in  most  cases  the  exact  date  at  which 
it  began.  It  probably  varies  from  eleven  to  four- 
teen days,  the  average  being  twelve  days.  If  six- 
teen days  have  passed  after  exposure  without  the 
occurrence  of  any  cough,  the  disease  has  probably 
not  been  contracted. 

Owing  to  the  serious  nature  of  whooping-cough 
in  young  or  feeble  children,  greater  caution  should 
be  observed  in  its  prevention  than  it  usually 
receives.  Children  with  a  predisposition  to  tuber- 
culosis should  be  protected  against  exposure  with 
particular  care.  As  exposure  usualh^  results 
directly  from  the  patient,  prevention  is  not 
especially  difficult.  The  chief  point  of  difficulty 
lies  in  the  fact  that  between  the  paroxysms  the 


no  HOW   TO    KEEP   WELL 

patient  is  usually  not  very  ill,  and  the  long  period  of 
isolation  becomes  very  irksome.  Nevertheless,  it  is 
an  unjustifiable  invasion  of  the  rights  of  others  to 
permit  a  child  suffering  from  whooping-cough  to 
go  into  public  places.  He  should  be  allowed  to  go 
into  the  open  air  as  much  as  possible  without 
mingling  witli  other  chlidren,  and  should  not  be 
confined  to  a  single  room.  It  is  wise,  therefore, 
when  such  an  arrangement  can  be  made,  to  send 
the  other  children  of  the  family  away  from  home. 
The  seashore  is  an  especially  favourable  place  for 
children  with  whooping-cough.  Unless  it  has 
been  necessary  to  confine  the  child  quite  closely  to 
one  or  two  rooms,  fumigation  is  not  required. 
Thorough  airing  of  the  rooms  is  sufficient. 

INFLUENZA 

Influenza,  or  la  grippe,  is  a  contagious  disease 
characterized  by  extreme  prostration,  and  fre- 
quently by  catarrh  of  the  mucous  membrane. 
Pneumonia  is  one  of  its  most  frequent  and  serious 
complications.  It  is  one  of  the  few  diseases  of 
modern  times  which  has  appeared  in  pandemic 
form.  It  has  been  known  since  the  twelfth  cen- 
tury. A  marked  peculiarity  of  its  occurrence  is 
its  tendency  to  widespread  epidemics,  followed  by 
periods  of  complete  dissapearance.  During  the 
past  century  there  were  four  severe  epidemics  in 


THE    INFECTIOUS   DISEASES 


III 


this  country.  The  last  of  these  was  peculiar  in  its 
marked  persistence  for  several  years  after  its 
acute  onset.  As  a  rule,  it  has  died  out  in  two  or 
three  seasons.  Pandemics  have  all  begun  in 
eastern  Russia  or  central  Asia.  In  that  of  1889, 
influenza  was  knovv^n  to  be  present  in  eastern 
Russia  in  October.  It  reached  Moscow  early  in 
November,  and  Berlin  by  the  middle  of  the  month. 
It  appeared  in  London  early  in  December,  and  in 
New  York  a  few  days  before  Christmas.  No  other 
modern  disease  is  so  rapid  in  its  spread,  and  no 
other,  except  dengue,  attacks  so  large  a  proportion 
of  the  inhabitants.  Cases  that  appear  in  the  early 
stages  of  the  epidemics  have  usually  been  more 
serious  than  those  of  the  last  stages.  One  attack 
does  not  confer  immunity,  but  the  same  individual 
may  suffer  time  after  time. 

The  germ  of  true  influenza  is  the  bacillus  influ- 
enzcB  of  Pfeiffer.  It  occurs  in  large  numbers  in  the 
discharges  of  the  nose,  throat,  and  bronchi.  It  is 
cultivated  with  difficulty  outside  the  body,  and  is 
quickly  destroyed  by  drying.  It  is  very  small  in 
size,  and  does  not  produce  spores. 

Influenza  is  usually  classed  as  pandemic,  epi- 
demic, and  endemic.  The  pandemics  are  due  to 
Pfeiffer's  bacilli,  and  are  true  influenza.  The  epi- 
demics,  which  for  several "  years   follow  the  pan- 


112  HOW  TO   KEEP   WELL 

demic,  are  also  true  influenza.  The  true  disease 
may  also  occur  endemically  in  sporadic  cases. 
There  is,  however,  a  pseudo-influenza  or  catarrhal 
fever  which  closely  simulates  grippe.  It  is  a  specific 
disease,  but  is  not  due  to  the  bacillus  influenzce,  but 
to  some  other  germ  which  has  not  been  discovered. 
This  pseudo-influenza  occurs  in  sporadic  cases  or 
even  epidemic  form,  and  was  seen  by  practitioners 
during  the  winter  and  spring  months  before  the 
appearance  of  the  last  great  epidemic.  While  true 
influenza  occurred  in  epidemics  for  years  after  its 
appearance  in  1889,  most  of  the  so-called  cases  of 
grippe  since  1900  have  been  catarrhal  fever  rather 
than  true  epidemic  influenza.  The  term  grippe, 
however,  has  become  firmly  established,  and  to  the 
patient  it  makes  but  little  difference  by  what  name 
it  is  called,  for  he  is  miserable  under  any  name. 
While  the  feeling  of  wretchedness  and  prostration 
is  common  to  all  forms  of  the  disorder,  the  after- 
results  of  catarrhal  fever  are  less  serious  and  pro- 
longed than  are  those  of  true  grippe.  Pneumonia 
is  less  common,  and  the  disease  in  subjects  of  ordi- 
nary strength  is  rarely  fatal. 

The  extraordinary  rapidity  of  the  spread  of 
epidemic  influenza  has  led  to  the  belief  that  it  is 
conveyed  by  winds,  but  this  has  not  been  sub- 
stantiated.    The   rapidity   with   which   the   germs 


THE    INFECTIOUS    DISEASES  113 

are  destroyed  by  drying  would  seem  to  disprove 
this  theory.  These  epidemics  can  usually  be  traced 
along  the  lines  of  human  travel  and  communica- 
tion. Many  peculiar  cases  could  be  cited  in  which 
the  disease  was  raging  in  a  community  while  some 
public  institution  remained  entirely  free.  Suddenly 
one  case, would  be  brought  in  from  outside,  when 
the  disease  would  promptly  break  out  and  affect 
large  numbers  of  the  inmates.  It  must  be  said, 
however,  that  the  occurrence  of  grippe  in  a  few 
localities  has  not  been  satisfactorily  explained  as 
being  carried  by  human  agency. 

Prevention  during  times  of  epidemic  is  extremely 
difficult.  The  disease  is  contagious  from  the  first 
catarrhal  symptoms,  and  sometimes  earlier.  It  is 
so  widely  prevalent  that  there  is  no  practical  way 
of  escaping  it  unless  a  person  live  a  hermit-like 
existence.  A  large  proportion  of  cases  are  "walk- 
ing" cases,  and  there  is  no  protection  against  them 
for  those  who  go  into  public  places.  The  disease 
affords  some  peculiar  examples  of  personal  im- 
munity, some  escaping  it  through  epidemic  after 
epidemic.  The  chief  preventive  measure  for  the 
ordinary  individual  is  to  maintain  as  good  a  condi- 
tion of  bodily  health  as  may  be  possible.  This 
apparently  aids  somewhat  in  preventing  the  disease, 
and    is    of    material    assistance    in  modifying    its 


114  HOW    TO    KEEP    WELL 

severity  and  depressing  effects  upon  those  who 
contract  it.  Where  there  is  a  sporadic  case,  its 
spread  may  perhaps  be  prevented  by  isolation  and 
the  boihng  of  all  articles  which  could  have  been 
soiled  by  the  secretions  of  the  throat  or  nose. 

PNEUMONIA 

Acute  pneumonia  appears  under  two  different 
forms,  lobar  pneumonia  and  broncho -pneumonia. 
These  two  forms,  while  presenting  many  symptoms 
in  common,  have  also  some  radical  differences. 

Lobar  pneumonia,  sometimes  known  as  lung- 
fever  or  inflammation  of  the  lungs,  is  the  form 
commonly  seen  in  adult  life.  It  is  an  infectious, 
and  perhaps  transmissible,  disease,  but  it  is  prob- 
ably not  contagious.  Typical  cases  pursue  the 
following  course :  The  onset  •  is  marked  by  a 
severe  chill,  followed  by  a  fever  which  continues 
with  slight  remissions  five  or  seven  days.  In 
favourable  cases  tlie  fever  then  falls  abruptly  and 
the  case  terminates  by  crisis.  Cough,  catching 
pain  in  the  side,  and  panting  respiration  are 
usually  present.  Pneumonia  is  one  of  the  few 
diseases  that  terminates  with  a  definite  crisis,  but 
the  exact  hour  or  even  the  day  on  which  this  crisis 
may  appear  in  any  particular  case  can  rarely  be 
foretold.  The  term  lobar  has  been  given  to  this 
form  of  pneumonia  because  it  involves  complete 


THE    INFECTIOUS    DISEASES  115 

lobes  of  the  lung.  The  right  lung  is  divided  into 
three  great  divisions  or  lobes,  the  left  lung  into  two. 
At  least  one  of  these  lobes  becomes  solidified  by 
the  filling  up  of  the  air  spaces  with  inflammatory 
material.  The  seriousness  of  the  disease  results 
to  but  slight  degree  from  local  obstruction,  but 
rather  from  the  constitutional  effects  of  the 
pneumonic  poison. 

Pneumonia  in  its  different  forms  is  the  most 
widely  spread  and  fatal  of  all  the  acute  diseases. 
It  occurs  in  all  countries,  but  is  most  frequent  in 
northern  latitudes.  In  New  York  it  is  most 
common  in  February,  March,  and  April.  It 
attacks  men  more  frequently  than  women,  and  is 
a  particularly  fatal  disease  among  men  in  active 
middle  life.  It  has  greatly  increased  during  the 
past  ten  years,  due  in  large  part  to  the  numerous 
epidemics  of  influenza.  It  has  been  a  frequent 
complication  of  influenza,  and  has  been  the  direct 
cause  of  a  great  proportion  of  fatalities  which  have 
resulted  from  it.  Observations  made  in  the 
Massachusetts  General  Hospital  show  that  there 
has  been  no  increase  in  mortality  from  decade 
to  decade  in  cases  uncomplicated  by  influenza  or 
similar  conditions.  The  mortality  increases  with 
each  decade  of  life,  ranging  from  3.7  per  cent, 
under  the  twentieth  year  to   47  per  cent,  in  the 


ii6  HOW   TO    KEEP    WELL 

fifth    decade,    and    65    per    cent,    in    the    seventh 
decade. 

Of  the  predisposing  causes,  alcohoUsm  is  the 
most  potent.  Chronic  users  of  alcohol  are  par- 
ticularly liable  to  the  disease,  and  in  them  it  is 
especially  fatal.  Debilitating  causes  of  all  kinds 
tend  to  render  an  individual  susceptible.  This  is 
particularly  true  of  chronic  diseases,  like  Bright 's 
disease  and  diabetes.  Pneumonia,  in  fact,  is 
peculiar  in  being  the  most  frequent  of  the  "  terminal 
diseases."  Contrary  to  the  common  belief,  many 
of  the  chronic  diseases,  and  even  some  of  the  acute 
diseases,  do  not  of  themselves  directly  cause  a  large 
mortality.  They  terminate  by  one  of  the  so-called 
terminal  diseases,  of  which  pneumonia  is  the  most 
common.  When  the  vital  forces  are  reduced  by 
chronic  conditions  the  patient  becomes  particularly 
susceptible  to  acute  infections.  Chronic  alcohol- 
ism, for  example,  rarely  proves  fatal  in  such  a  way 
that  the  cause  is  assigned  to  alcoholism  in  the  death 
certificates.  It  commonly  ends  through  a  terminal 
disease,  of  which  pneumonia,  and  disease  of  the 
kidney,  liver,  and  arteries,  are  the  most  common. 
In  speaking  of  chronic  disorders.  Doctor  Osier  has 
made  the  true  but  apparently  paradoxical  state- 
ment that  people  rarely  die  of  the  disease  from 
which  they  suffer. 


THE    INFECTIOUS    DISEASES  117 

The  germ  of  lobar  pneumonia  is  the  micrococcus 
lanceolatus,  sometimes  known  as  the  pneumococcus 
of  Fraenkel.  In  rare  cases  other  germs  may  cause 
this  type.  The  pneumococcus  is  a  germ  of  low 
resisting  power,  and  is  easily  destroyed  by  heat 
and  disinfectants.  It  is  cultivated  with  difficulty, 
but  is  pathogenic  for  white  mice  and  rabbits,  so  that 
it  has  been  possible  to  study  its  habits  and  methods 
of  action.  It  is  a  widespread  organism,  and  is 
frequently  found  in  the  throats  of  healthy  people. 
It  has  long  been  a  popular  belief  that  exposure  to 
cold  or  chilling  of  the  body  is  a  potent  cause  of 
pneumonia.  It  is  certainly  not  a  necessary  cause, 
for  in  a  majority  of  cases  no  history  of  such  chilling 
can  be  obtained,  while,  on  the  other  hand,  exposure 
occurs  hundreds  of  times  without  resulting  in 
pneumonia.  A  chill,  by  causing  a  congestion  of 
the  mucous  membranes  and  the  removal  of  the 
protecting  cells  from  their  surface,  may  render 
it  possible  for  pneumococci  to  gain  a  foothold.  A 
single  experiment  explains  much  in  this  direction. 
Pure  cultures  of  pneumococci  were  injected  into 
the  lungs  of  healthy  rabbits  with  the  result  of 
causing  nothing  more  than  temporary  irritation. 
Rabbits  exposed  to  the  fumes  of  ammonia  gas  until 
their  bronchial  membranes  had  become  irritated 
and    congested,    were    then    treated    in    the    same 


ii8  HOW   TO    KEEP    WELL 

manner  and  promptly  developed  pneumonia. 
Observations  of  this  character,  as  well  as  e very-day 
experience,  confirms  the  belief  that  some  of  the 
common  predisposing  causes  are  active  factors  in 
precipitating  an  attack. 

The  germ  of  pneumonia  maintains  its  vitality 
for  long  periods  of  time  in  such  elements  as  sputum 
and  blood.  When  sputum  containing  them  has 
been  dried  and  converted  into  powder,  they  have 
been  found  to  be  virulent  for  as  long  as  forty-five 
days.  It  seems  probable,  therefore,  that  pneu- 
monic sputa  which  has  become  dried  and  pulverized 
may  disseminate  the  disease  as  sputa  containing 
the  germs  of  tuberculosis  disseminate  that  disease. 
It  is  at  least  certain  that  the  germs  appear  to  be 
derived  from  a  place  rather  than  a  person,  unclean 
houses  being  especially  adapted  to  their  growth. 
During  the  construction  of  the  new  New  York 
City  Croton  Aqueduct  an  epidemic  of  pneu- 
monia broke  out  in  several  houses  in  which 
gangs  of  men  were  quartered.  Upon  the  removal 
of  the  men  to  other  places  it  ceased,  but 
on  their  return  to  the  same  houses  it  reap- 
peared, to  disappear  upon  their  again  being 
removed.  The  pneumonic  germs  were  found  in 
large  numbers  in  the  rooms  of  these  houses. 
Reports  are  numerous  of  the  same  experience  in 


THE    INFECTIOUS   DISEASES  119 

prisons,  almshouses,  and  other  places.  Pneumonia 
most  frequently  occurs  in  those  who  live  much  in 
the  house  and  little  in  the  open  air.  It  is  not 
necessary  to  isolate  the  pneumonia  patient,  nor  is 
fumigation  or  other  measures  of  like  nature 
required  if  proper  precautions  have  been  taken  in 
the  disposal  of  the  sputa.  As  it  seems  clear  that 
the  chief  mode  of  dissemination  is  by  the  sputum,  it 
should  be  cared  for  with  the  same  precautions  as 
were  directed  for  the  care  of  tuberculous  sputa. 
The  attendants  should  be  particularly  careful  in 
the  washing  of  their  hands  and  in  all  other  details 
of  cleanliness. 

BroncJw-Pnciunonia. — This  form  of  pneumonia 
is  essentially  a  disease  of  young  children.  It  is 
sometimes  called  catarrhal  or  lobular  pneumonia. 
The  latter  term  is  used  because  the  disease  involves 
not  a  whole  lobe  of  the  lung,  but  scattered  lobules. 
It  does  not  pursue  as  clear-cut  and  definite  a 
course  as  does  lobar  pneumonia.  It  may  pass 
away  in  a  few  days  or  continue  day  after  day  for 
weeks,  extending  from  one  portion  of  the  lung  to 
another.  It  rarely  begins  abruptly,  but  is  slow  in  its 
onset,  and  frequently  follows  bronchitis.  It  termi- 
nates gradually,  a  crisis  being  rare.  More  commonly 
it  runs  its  course  in  from  one  to  two  weeks, 
but  sometimes  continues  for  four  weeks  or  longer. 


I20  HOW   TO    KEEP   WELL 

Broncho-pneumonia  may  appear  as  a  primary 
or  secondary  disease.  By  the  first  of  these  terms 
is  meant  that  it  occurs  independently  without  any 
preceding  disease.  By  the  second  is  meant  that 
it  follows  or  complicates  some  other  disease, 
usually  an  infectious  one.  It  may  be  secondary 
to  the  following  diseases,  mentioned  in  the  order  of 
their  frequency:  measles,  whooping-cough,  diph- 
theria, bronchitis,  acute  diarrhea  scarlet  fever, 
and  influenza. 

Broncho-pneumonia  is  not  as  distinct  an  entity 
as  is  lobar  pneumonia,  but  may  be  the  result  of 
the  action  of  various  germs.  In  primary  cases 
the  pneumococcus  is  nearly  always  present,  and 
usually  occurs  alone.  The  secondary  cases  are 
commonly  mixed  infections,  for  streptococci  and 
the  bacillus  of  Friedlander  are  often  present. 
This  is  quite  to  be  expected  when  it  is  known  that 
the  disease  is  so  frequently  an  accompaniment  of 
the  infectious  diseases.  As  explained  under  the 
head  of  septic  infection,  streptococcus  infections 
are  apt  to  be  widespread,  and  very  resistant  to 
treatment.  Following  this  principle,  streptococcus 
pneumonias  are  prone  to  be  prolonged  and  cause 
the  death  of  the  child  by  exhaustion.  Pneumonia 
of  this  type  sometimes  continues  week  after  week, 
with    improvement    in    one    locality    only,   to   be 


THE    INFECTIOUS   DISEASES         121 

followed  by  the  lighting  up  of  a  new  focus  in 
another.  Among  babies  and  young  children 
broncho-pneumonia  is  a  very  grave  and  fatal 
disease.  The  most  experienced  physician  cannot 
foretell  with  certainty  the  course  which  it  will 
take,  for  a  new  focus  may  suddenly  develop 
without  warning.  They  are  among  the  most 
trying  diseases  for  physicians  owing  to  this 
characteristic  of  uncertainty,  and  also  to  the  fact 
that  the  portions  of  the  lung  involved  may  be  so 
scattered  that  it  is  difficult  to  detect  them  by 
physical  examination. 

The  bacillus  of  tuberculosis  is  capable  of  pro- 
ducing broncho-pneumonia  which  cannot  in  the 
early  stage  be  distinguished  from  types  produced 
by  other  germs.  It  is  one  of  the  most  common 
forms  of  tubercular  onset.  Broncho-pneumonia 
sometimes  occurs  among  the  aged,  and  is  not  an 
infrequent  terminal  disease  in  the  late  decades  of 
life.  A  type  of  pneumonia  sometimes  known  as 
senile  pneumonia  is  one  of  the  most  common 
causes  of  death  among  the  aged.  It  is  insidious 
in  its  onset  and  development,  and  produces  few 
of  the  typical  symptoms  commonly  seen  in  earlier 
years.  There  may  be  little  or  no  cough,  expecto- 
ration, or  pain. 

Measures    of   prevention   required   for   broncho- 


122  HOW   TO   KEEP   WELL 

pneumonia  are  virtually  the  same  as  those  sug- 
gested for  lobar  pneumonia.  Rickets  and  mal- 
nutrition render  a  child  especially  susceptible  to 
pneumonia;  the  most  serious  and  fatal  cases  are 
those  which  occur  among  poorly  nourished  infants. 
They  do  not,  however,  hold  a  monopoly  upon 
the  disease,  for  it  not  infrequently  occurs  without 
warning  and  apparently  without  reason  among  the 
healthiest  and  most  perfectly  nourished  children. 
The  outcome  in  such  cases,  however,  is  usually 
much  better  than  among  the  ill-nourished. 

.     PLEURISY 

Pleurisy  is  an  inflammation  of  the  pleura,  and 
usually  results  in  a  collection  of  fluid  in  the  pleural 
cavity.  The  pleura  is  the  lining  membrane  of 
the  chest  wall,  from  which  it  is  reflected  onto  the 
surface  of  the  lung.  It  thus  forms  a  cavity,  the 
walls  of  which  lie  in  apposition.  It  is  a  polished 
membrane  designed  to  prevent  friction  between 
the  chest  and  the  lung  in  breathing.  It  corre- 
sponds to  the  peritoneum  in  the  abdomen.  In 
health  it  is  moistened  by  a  slight  secretion  of  serum. 
When  inflamed,  this  secretion  is  increased,  and 
having  no  exit  from  the  pleural  cavity,  it  must 
collect.  The  amount  often  becomes  large,  and  as 
a  result  the  lung  is  compressed  into  the  upper 
part   of   tlie    chest.      At   the    outset   the   rubbing 


THE    INFECTIOUS   DISEASES         123 

together  of  the  .surfaces  causes  agonizing  pain,  but 
later,  when  the  fluid  has  separated  them,  the  pain 
ceases.  When  the  fluid  consists  of  serum  alone  it  is 
often  absorbed  after  the  inflammation  has  run  its 
course.  In  some  cases'  a  portion  must  be  drawn 
away  through  a  hollow  needle,  when  the  rest  will 
be  removed  by  absorption. 

Sometimes  the  fluid  in  the  chest  is  pus.  This  is 
a  very  grave  condition,  for  the  pus  will  never 
be  absorbed,  and  general  infection  and  exhaustion 
follow  if  lit  is  allowed  to  remain.  This  condition 
is  known  as  empyema.  It  is  more  common  in 
children  than  in  adults.  In  early  life  it  rarely 
occurs  except  as  a  sequel  to  pneumonia.  It  is 
then  caused  chiefly  by  the  pneumococcus,  alone 
pr  accompanied  by  the  pus-forming  germs.  In 
adults  empyema  is  commonly  due  to  streptococci 
or  tubercle  bacilli.  The  only  adequate  treat- 
ment is  removal  of  the  pus  by  an  incision  through 
the  chest  wall  and  the  insertion  of  a  drainage 
tube.  This  operation  should  be  performed  as  soon 
as  the  diagnosis  is  made.  AVhen  performed  earty, 
before  the  lung  has  been  long  compressed  and  the 
strength  of  the  patient  has  been  exhausted,  the 
death  rate  is  small.  When  it  is  delayed,  the 
death  rate  is  very  large,  and  recovery,  if  it  takes 
place,    is    slow    and    tedious.     Deformity    of    the 


124  HOW   TO    KEEP   WELL 

chest  rarely  takes  place  after  early  operation,  but 
is  common  when  it  has  been  delayed. 

The  bacteria  which  cause  pleurisy  and  empyema 
reach  the  pleura  by  way  of  the  lungs.  The  pre- 
vention of  pleurisy,  therefore,  consists  in  exclud- 
ing bacteria  from  the  bronchial  tubes  and  lungs, 
particularly  those  which  cause  tuberculosis,  pneu- 
monia, and  bronchitis. 

MENINGITIS 

Meningitis  is  an  inflammation  of  the  meninges, 
or  envelopes  of  the  brain.  It  is  sometimes,  in 
popular  language,  referred  to  as  brain  fever,  or 
inflammation  of  the  brain.  Inflammation  of  the 
brain  itself  is  a  rare  condition.  Meningitis  in  its 
various  forms  is  not  uncommon.  It  is  a  com- 
plex and  difficult  subject  to  describe  clearly. 
The  acute  disease  results  from  various  causes. 
First,  it  occurs  as  an  epidemic  disease  known 
as  epidemic  cerebro-spinal  meningitis,  or  spotted 
fever.  Second,  it  occurs  in  sporadic  cases,  and  runs 
a  course  almost  identical  with  that  of  the  epidemic 
disease.  Third,  it  is  sometimes  caused  by  the 
bacillus  tuberculosis,  in  which  case  it  runs  a  char- 
acteristic course  which  always  terminates  fatally. 
Fourth,  it  sometimes  occurs  as  a  complication 
of  typhoid  fever,  pneumonia,  scarlet  fever,  small- 
pox,    and     other     infectious     diseases.     In     such 


THE    INFECTIOUS   DISEASES         125 

cases  it  is  caused  by  the  action  on  the  meninges 
of  the  germ  which  causes  the  original  disease. 
Fifth,  it  may  result  from  an  extension  of  inflamma- 
tion from  adjoining  structures.  It  thus  some- 
times follows  inflammation  of  the  middle  ear  or 
injury  to  the  bones  of  the  head.  Sixth,  there 
are  a  few  cases  in  which  meningitis  seems  to  be 
due  to  exposure  to  wet  or  cold,  but  such  cases  are 
no  doubt  also  due  to  some  form  of  germ  infection. 
Epidemic  cerebro-spinal  meningitis  is  usually 
due  to  the  diplococciis  intracellularis ,  so  called 
because  it  is  a  double  germ  which  is  found  within 
the  body  of  the  pus  cells  which  form  on  the  inflamed 
membranes  of  the  brain  and  spinal  cord.  The 
first  extensive  epidemic  occurred  in  this  country 
in  1806,  the  last  during  1876.  Since  that  time 
it  has  been  endemic  in  most  large  cities.  A  peculiar 
feature  of  the  disease  is  its  tendency  to  appear 
simultaneously  in  a  number  of  individuals,  and 
not  by  person  to  person  extension.  Epidemics 
often  appear  in  widely  separated  communities. 
The  disease  varies  considerably  in  its  severity  in 
different  epidemics.  A  virulent  type  may  appear 
at  one  time,  while  at  another  it  may  be  compara- 
tively mild.  The  mortality  ranges  all  the  way 
from  25  to  70  per  cent.;  it  is  more  commonly 
above  than  below  50  per  cent. 


126  HOW   TO    KEEP   WELL 

Epidemic  meningitis  is  a  disease  of  childhood 
and  early  adult  life,  being  rare  after  thirty  years 
of  age.  While  it  is  somewhat  more  common 
among  the  poorer  classes  of  large  cities,  it  occurs 
also  among  the  wealthy.  But  little  has  been 
discovered  regarding  the  mode  of  infection  or  the 
portal  of  entrance  of  the  specific  germ,  although 
many  excellent  observers  have  made  these  ques- 
tions a  study.  The  diseased  tissues  are  enclosed 
within  bony  cavities,  and  the  route  along  which 
the  germs  must  pass  to  gain  admission  to  them  is 
not  wholly  clear.  It  is  probable  that  they  enter 
through  the  tonsils  or  tissues  at  the  back  of  the 
throat,  from  which  the  passage  by  way  of  the 
lymphatic  vessels  is  short.  In  view  of  the  location 
of  the  disease,  it  would  seem  doubtful  whether 
it  could  be  conveyed  by  contact  from  one  to 
another.  Observation,  in  fact,  seems  to  show 
that  it  is  not  contagious,  although  in  rare  cases 
more  than  one  member  of  a  family  suffers  from  it. 
Such  cases  are  probably  irffected  from  a  common 
source.  As  it  is  probable  that  the  disease  is  not 
transmitted  from  person  to  person,  rigid  isolation 
does  not  seem  to  be  necessary.  As  the  methods 
of  transmission  are  uncertain,  however,  it  is  a 
wise  precaution  to  keep  children  and  young  adults 
from    contact    with    those    who    are    ill.     As    the 


THE    INFECTIOUS   DISEASES         127 

bacilli  are  contained  in  the  pus  cells,  any  purulent 
discharge  from  nose,  ear,  or  other  locality  should 
be  disinfected,  and  all  articles  soiled  with  them 
should  be  burned  or  disinfected. 

The  cases  of  cerebro-spinal  meningitis  which 
occur  sporadically  are  occasionally  due  to  the  germ 
which  causes  the  epidemic  variety,  but  a  certain 
form  of  streptococcus  and  the  pneumococcus  are 
the  bacteria  most  frequently  found.  Such  cases 
show  no  tendency  to  epidemic  occurrence.  The 
symptoms  are  very  similar  to  those  of  the  epidemic 
form.  It  is  not  contagious,  nor  is  it,  as  a  rule,  so 
often  fatal  as  the  epidemic  variety. 

RHEUMATISM  ' 

Rheumatic  fever  is  an  acute,  non-contagious, 
infectious  disease,  characterized  by  inflammation 
of  several  joints  of  the  body,  having  a  peculiar 
tendency  to  pass  from  joint  to  joint.  It  is  self- 
limiting,  but  pursues  a  somewhat  variable  course. 
It  is  a  disease  of  temperate  climates,  and  is  most 
common  during  the  spring  months.  It  is  endemic 
in  most  cold  and  damp  climates,  but  appears  in 
indefinite  epidemics  at  irregular  intervals.  It 
affects  young  adults  chiefly,  about  half  of  all  the 
cases  occurring  between  the  ages  of  fifteen  and 
twenty-five  years.  After  forty-five  acute  rheu- 
matism is  not  common.     It  should  be  understood 


128  HOW   TO    KEEP   WELL 

that  we  are  now  considering  "inflammatory 
rheumatism,"  and  not  the  so-called  muscular  or 
chronic  rheumatism  common  to  middle  and  later 
Hfe. 

The  infective  agent  has  not  been  discovered,  but 
analogy  leads  very  strongly  to  the  belief  that  such 
an  agent  exists.  It  seems  to  be  allied  with  the 
septic  diseases,  and  shows  many  characteristics  of 
septic  infection.  The  more  accurate  methods  of 
observation  of  recent  years  eliminate  many  dis- 
orders which  were  formerly  known  as  rheumatism. 
Some  of  these,  like  chronic  deforming  rheumatism, 
are  in  no  sense  rheumatic  in  their  nature,  while 
others  belong  to  the  gouty  family.  The  term 
"rheumatism"  is  properly  applied  to  those  acute 
and  subacute  conditions  which  are  marked  by 
involvement  of  the  joints  and  fibrous  structures, 
and  have  a  tendency  to  involve  certain  of  the 
internal  organs,  notably  the  heart.  The  rheumatic 
group  of  diseases  includes  not  only  iheumatic  fever, 
but  tonsilitis,  St.  Vitus 's  dance,  certain  forms  of 
skin  eruptions,  and  acute  disease  of  the  heart. 

Heredity  is  a  strong  predisposing  factor,  being  an 
active  element  in  at  least  two-thirds  of  the  cases  in 
early  life.  Exposure  to  cold  and  wet,  and  living  in 
damp  dwellings  under  poor  hygienic  surroundings, 
with  insufficient  food,  are  among  the  predisposing 


THE    INFECTIOUS    DISEASES  129 

causes.  A  cold,  damp  climate  with  clayey  soil  also 
predisposes  it.  As  but  little  is  known  of  the 
exciting  cause,  prevention  consists  chiefly  in  the 
elimination  of  the  disposing  cause  as  far  as  it  is 
possible. 

Much  may  be  done  to  prevent  the  occurrence  of 
the  disease  in  the  children  of  rheumatic  families. 
The  management  of  these  rheumatic  children 
(for  where  the  family  is  strongly  rheumatic  the 
child  is  very  prone  to  be)  is  included  under  four 
headings:  clothing,  exercise,  diet,  and  medication. 
The  rheumatic  child  should  wear  flannels  at  all 
seasons,  though  during  the  summer  it  may  be  of 
thin  texture.  Its  value  as  a  means  of  prevention 
has  been  too  well  established  to  be  doubted.  As 
the  belief  is  growing  that  the  tonsils  form  at  least 
one  portal  of  entry  for  the  rheumatic  poison, 
another  reason  is  added  to  many  for  removing  the 
enlarged  portion  of  those  organs  when  they  are 
diseased.  The  exercise  and  outdoor  life  of  the 
rheumatic  child  should  receive  particular  attention. 
There  is  a  strong  tendency  on  the  part  of  mothers 
to  confine  their  children  too  closely  to  the  house, 
thus  rendering  them  the  more  susceptible  to  cold. 
On  the  other  hand,  there  are  many  days  during  the 
winter  and  spring  in  which  a  child  of  rheumatic 
tendency  should  be  kept  in  the  house.     Days  of 


I30  HOW   TO    KEEP   WELL 

damp  east  wind,  particularly  if  the  ground  be 
covered  with  slush  or  melting  snow,  are  especially 
favourable  for  the  development  of  rheumatism. 
Here,  as  in  so  many  other  places  in  the  manage- 
ment of  children,  the  golden  mean  is  the  middle 
course  between  too  much  coddling  on  the  one  hand 
and  too  much  exposure  in  foolish  attempts  at 
hardening  on  the  other. 

The  diet  of  the  child  or  the  adult  of  rheumatic 
tendency  was  formerly  looked  upon  as  of  more 
importance  than  it  is  at  the  present  time.  When 
the  acid  theory  was  more  generally  held,  and  when 
the  difference  between  rheumatism  and  gout  was 
not  as  well  understood,  it  was  natural  that  diet 
should  be  looked  upon  as  of  utmost  importance. 
We  should  not,  however,  go  to  the  other  extreme 
and  neglect  it.  It  is  not  necessary  to  wholly 
eliminate  meat  and  other  nitrogenous  food  from 
the  diet  of  rheumatic  subjects,  though  it  is  wise  to 
reduce  it  if  there  is  a  tendency  to  take  it  in  excess. 
Restriction  should  rather  be  made  in  the  direction 
of  sugar  and  starches.  A  diet  consisting  largely 
of  starches  and  overcharged  with  sugar  is  the  worst 
possible  one  for  a  rheumatic  child.  Candy  should 
be  absolutely  forbidden.  The  rheumatic  child  is 
prone  to  be  anemic,  and  a  plain  but  generous 
nourishing  diet  which  contains  no  one  food  element 


THE    INFECTIOUS   DISEASES         131 

in  excess  is  the  best.  It  is  to  be  understood  that 
this  advice  is  given  for  those  subject  to  rheumatism, 
and  not  to  those  of  gouty  famihes  or  for  elderly- 
people  with  a  strongly  marked  gouty  and  uric  acid 
tendency. 

Rheumatic  subjects,  particularly  children,  be- 
come readily  anemic,  and  one  of  the  most  potent 
measures  of  prevention  is  the  maintenance  of 
nutrition  and  the  prevention  of  anemia.  Those 
children  of  rheumxatic  tendency  who  are  prone  to  be 
anemic  should  receive,  in  addition  to  particular 
personal  care  and  good  diet,  certain  tonic  prepara- 
tions at  regular  intervals.  They  may  thus  take  a 
mild  preparation  of  iron.  Cod-liver  oil  is  of  par- 
ticular value  to  such  children.  It  may  often  be 
given  with  great  advantage  for  one,  two  or  three 
weeks  of  each  month  during  the  cold  weather. 
For  children,  cod-liver  oil  should  be  regarded  as  a 
food  rather  than  a  medicine.  In  those  of  pro- 
nounced rheumatic  tendency  the  importance  of 
nutrition-improving  treatment  cannot  be  too 
strongly  urged  as  a  preventive  of  acute  attacks. 

The  most  serious  aspect  of  rheumatism  is  its 
tendency  to  affect  the  heart.  Most  of  the  valvular 
heart  disease  of  middle  life  is  due  to  rheumatic 
attacks  during  childhood  and  youth.  At  that 
time  of  life  the  disease  is  peculiar  in  that  the  joint 


132  HOW   TO    KEEP   WELL 

symptoms  are  prone  to  be  slight  while  the  tendency 
to  heart  comp  heat  ion  is  great.  No  rheumatic 
attack  in  a  child  is  so  slight  as  to  be  free  from  pos- 
sible danger.  Even  in  the  mildest  attacks,  the 
child  should  be  kept  absolutely  in  bed  until  every 
symptom  has  passed.  This  is  the  most  potent 
preventive  measure  that  can  be  taken  against 
that  grave  condition — valvular  heart  disease. 

MALARIAL     FEVER 

The  term  malarial  fever  is  used  to  designate 
several  forms  of  disease  which  result  from  the 
presence  in  the  blood  of  an  animal  parasite  dis- 
covered by  Laverlan  and  known  as  the  Plasmodium 
nialarice.  These  fevers  appear  under  two  general 
forms — intermittent  and  remittent.  The  inter- 
mittent fevers  are  most  characteristic,  and  when 
fully  developed  appear  in  paroxysms  consisting 
of  a  chill,  fever,  and  sweating.  This  order  is  always 
maintained.  The  occurrence  of  these  three  symp- 
toms in  different  order  is  the  result  of  some  disease 
other  than  malaria.  Intermittent  fever  appears 
in  three  general  types.  When  the  paroxysm 
occurs  every  day  the  disease  is  known  as  the 
"quotidian";  when  it  occurs  every  other  day,  as 
"tertian" ;  when  it  occurs  every  third  day,  as  "quar- 
tan." The  last  form  is  rare  in  northern  climates. 
Quotidian  fever  is  most  commonly  seen  in  children ; 


THE    INFECTIOUS   DISEASES  133 

tertian  is  the  type  common  to  adults.  In  remit- 
tent fever,  the  temperature  falls  between  the 
paroxysms,  but  does  not  reach  normal,  as  in 
intermittent. 

In  northern  latitudes  malarial  fever  is  rarely 
fatal,  but  in  tropical  regions  it  often  assumes  a 
pernicious  type  which  is  deadly.  When  the 
infection  is  intense,  the  paroxysm  comes  a  little 
earlier  each  day,  and  is  known  as  "  anticipating." 
In  this  way  a  tertian,  if  untreated,  may  become 
quotidian  in  type.  The  most  malignant  forms  of 
malarial  fever  are  seen  along  the  sea  coast  of 
tropical  countries.  It  is  particularly  prevalent 
in  low-lying  and  swampy  regions.  Marshes  that 
are  alternately  flooded  and  drained  imperfectly 
are  usually  malarial.  Salt  marshes  of  this  charac- 
ter form  some  of  the  most  dangerous  regions 
known.  The  great  number  of  cases  of  malarial 
fever,  however,  as  pointed  out  by  Sternberg,  do 
not  result  from  exposure  to  the  air  of  marshes,  but 
from  damp  bottom-lands,  from  alluvial  plains 
under  cultivation,  and  from  the  margins  of  streams 
which  are  exposed  during  the  dry  season.  This 
results  naturally  from  the  fact  that  malarious 
marshes  are  shunned,  while  the  rich  lands  of  the 
valleys  are  sought  for  agricultural  purposes.  Not- 
withstanding the  tendency  of  malaria  to  originate 


134  HOW   TO    KEEP   WELL 

from  marshes  and  low,  wet  ground,  the  rule  is  not 
invariable.  Certain  regions  which  apparently 
present  every  condition  for  malarial  development 
are  non-malarial.  It  has  long  been  observed 
that  a  wind  blowing  from  an  unusual  direction 
sometimes  carries  malaria  into  a  region  where  it 
is  rarely  known. 

Many  of  these  peculiarities  in  the  development 
of  malaria  were  difficult  of  explanation  until  the 
role  of  the  mosquito  in  disseminating  the  Plasmo- 
dium   was    demonstrated    in    very    recent    years. 
The  micro-organisms  concerned  in  the  production 
of  malaria  is  not  a  bacterium,  but  a  member  of  the 
lowest  order  of  the  animal  kingdom.     It  belongs 
to  the  protozoon  class,  a  parasite  which  multiplies 
by  means  of  spores.     It  is  found  in  the  red  cells  of 
the   blood.      Each   plasmodium   passes    through    a 
certain  life  cycle.     It  begins  as  a  small  structure- 
less  body,    and    fine   brown   granules   of   pigment 
gradually  appear  on  its  centre.     The  plasmodium 
grows    until  it  completely  fills  the  red  blood  cell, 
the    substance   of   which    it    absorbs    for    its    own 
nutrition.     The   pigment   granules   then   begin   to 
collect  in  groups  near  the  centre,  and  the  whole 
body     shows     faint     striations.     These     become 
deeper,  until  the  original  body  is  almost  divided 
into   segments,   numbering   from    five    to   twenty. 


THE    INFECTIOUS   DISEASES         135 

according  to  the  variety  of  plasmodium.  Just 
before  segmentation  these  bodies  are  regularly 
arranged  and  appear  under  the  microscope  like 
little  rosettes.  Separation  is  completed,  and  each 
segment  starts  on  a  new  cycle  of  life,  to  pass  through 
similar  stages  of  development.  There  are  several 
varieties  of  the  plasmodium  familv,  which  produce 
different  types  of  malarial  fever.  Quotidian 
fever,  in  which  the  paroxysms  occur  daily,  is  due 
to  two  sets  of  tertian  parasites,  each  set  running 
its  life's  course  in  forty-eight  hours,  but  maturing 
on  alternate  days,  thus  causing  a  daily  paroxysm. 
The  malarial  paroxysm  occurs  at  the  time  of 
segmentation  of  the  parasites.  So  invariable  is 
this  rule  that  an  expert  examining  the  blood  can 
tell,  almost  to  the  hour,  the  time  at  which  the 
paroxysm  will  occur.  The  commonly  accepted 
explanation  of  this  is  that  a  poison  is  eliminated 
at  the  time  of  segmentation.  It  is  this  poison 
which  causes  the  peculiar  combination  of  chill, 
fever,  and  sweat.  As  a  rule,  a  large  number  of 
parasites  segment  at  about  the  same  time  and 
eliminate  suddenly  a  large  amount  of  poison, 
which  produces  a  paroxysm.  The  poison,  being 
excreted  from  the  body  or  being  destroyed,  the 
patient  returns  to  his  usual  health.  After  a  short 
time,   however,   the   destruction   of  the   red  blood 


136  HOW   TO    KEEP    WELL 

cells  produces  anemia;  the  effect  of  the  poison 
becomes  less  transient,  and  the  patient  passes  into 
a  peculiar  anemic  state  known  as  cachexia.  If 
the  parasites  segment  at  varying  intervals,  we  get 
a  more  or  less  continued  fever.  If  a  majority  of 
them  segment  at  a  given  hour,  while  a  considerable 
portion  of  them  segment  at  irregular  intervals 
through  the  remaining  part  of  the  day,  we  have  a 
remittent  fever  in  which  the  temperature  fluctuates 
but  does  not  return  to  the  normal  point.  A  dose 
of  quinine  administered  shortly  before  the  par- 
oxysm is  followed  by  sluggishness  or  actual  death 
of  the  parasites.  They  fail  to  segment,  and  if  the 
dose  has  been  sufficiently  large  no  paroxysm 
occurs.  Many  of  the  spores,  however,  survive, 
and  after  a  time  a  sufficient  number  of  parasites 
have  developed  to  bring  about  another  paroxysm. 
The  spores  are  very  tenacious  of  life,  as  are  all 
spores,  and  repeated  doses  of  quinine  are  necessary 
for  their  complete  destruction.  It  has  been 
observed  that  certain  forms  of  plasmodium  are 
less  susceptible  to  the  effects  of  quinine  than  are 
others.  This  is  particularly  so  in  those  forms 
which  segment  at  irregular  intervals  and  thus 
cause  an  irregular  or  continued  type  of  disease. 

Many  of  these  facts,  particularly  the  effect  of 
quinine,  were  known  before  the  discovery  of  the 


THE    INFECTIOUS   DISEASES         137 

Plasmodium.  Very  few  scientific  discoveries  have 
so  beautifully  explained  the  cause  of  well-known 
phenomena.  Increased  knowledge  of  the  Plas- 
modium and  its  mode  of  transmission  explains 
more  and  more  fully  the  various  peculiarities  of 
these  particular  diseases.  Adding  of  the  last  links 
to  this  chain  of  knowledge  regarding  malaria  has 
been  the  work  of  very  recent  years.  After  the 
discovery  of  the  plasmodium,  the  mystery  as  to 
the  spread  of  malaria  was  even  greater  than  before. 
It  was  clear  that  the  infective  principle  was  not 
a  "miasm,"  or  vapour,  nor  even  a  light  germ  that 
could  float  in  the  air  when  dry,  but  a  comparatively 
large,  heavy,  moist  body,  which  could  not  be 
expected  to  float.  And  yet  it  was  clear  that  the 
infection  came  through  the  air.  There  was  abun- 
dant proof  in  many  cases  that  it  could  come  in  no 
other  way.  It  was  demonstrated  by  experiment 
that  the  parasites  could  not  enter  the  blood  by  way 
of  the  stomach.  Water  and  food  containing  them 
were  innocuous  when  swallowed.  With  increasing 
knowledge,  the  fact  became  more  plain  that  the 
disease,  in  some  places  at  least,  must  be  transmitted 
by  insects,  and  the  mosquito  was  finally  found  to 
be  the  criminal  engaged  in  the  nefarious  occupa- 
tion. It  was  soon  found  that  the  ordinary  mos- 
quito, although  a  pestiferous  insect,  could  not  be 


138  HOW   TO    KEEP   WELL 

charged  with  this  more  serious  crime,  but  only  the 
genus  known  as  the  Anopheles,  especially  the 
species  Anopheles  clavigcr. 

There  are  about  thirty  kinds  of  gnats  indigenous 
to  this  country.  The  term  "mosquito "  is  popularly 
applied  to  but  one  variety  of  this  group,  namely 
the  Culex.  The  following  are  the  more  important 
differences  between  the  Anopheles  and  the  Culex: 
The  Anopheles  is  of  slender  build,  the  body  is 
almost  straight,  and  the  wings  are  marked  by  dark 
spots.  When  the  insect  alights,  its  body  rests  at 
an  angle  of  about  forty-five  degrees  with  the  plane 
of  the  surface  on  which  it  is  resting.  That  is,  it  is 
a  straight  insect  with  its  body  elevated  in  the  air. 
The  Culex  is  of  heavier  build,  and  is  decidedly 
humpbacked.  The  wings  have  no  spots,  and  when 
the  insect  alights  its  body  is  almost  parallel 
with  the  surface  upon  which  it  is  resting. 

It  is  well  known  that  gnats  generate  in  water 
or  in  damp  places.  The  eggs  are  deposited  upon 
water,  and  when  they  hatch,  larvae  develop.  These 
larvae  may  be  seen  by  the  naked  eye  as  little, 
active,  rod-shaped  bodies  of  brownish  colour. 
They  move  about  with  a  wiggling  motion  near  the 
surface,  but  when  disturbed  they  instantly  seek 
the  bottom.  The  larvae  of  the  Culex  dive  directly 
downward  with  a  quick  motion,  while  those  of  the 


THE    INFECTIOUS    DISEASES         139 

Anopheles  glide  downward  with  an  oblique  slid- 
ing motion.  After  a  few  days  these  larvae  are 
transformed  into  pupae,  which  in  turn  develop 
into  mature  gnats.  About  a  month  is  required 
for  the  development  of  the  mature  mosquito 
after  the  eggs  are  deposited. 

The  mosquito  transmits  malaria  by  sucking 
the  blood  of  a  malarial  subject.  The  parasite  is 
then  taken  into  the  stomach  of  the  insect.  After 
several  changes  it  passes  into  the  salivary  glands, 
where  it  remains  till  the  mosquito  bites  its  next 
victim.  It  is  then  injected  into  the  tissues  of  the 
individual  upon  whom  the  mosquito  is  feeding. 
Having  once  become  infected,  the  disease  is  per- 
petuated in  the  Anopheles  family  of  that  particular 
locality.  Many  interesting  facts  regarding  the 
mosquitoes  of  the  United  States  are  contained  in 
Bulletin  No.  25  of  the  new  series  of  the  United 
States  Department  of  Agriculture. 

The  reason  why  some  marshy  and  low-lying 
grounds  are  not  malarial  has  been  made  clear. 
In  every  such  case  which  has  been  investigated 
the  Anopheles  has  been  conspicuous  by  its  absence, 
although  other  forms  of  mosquitoes  may  have 
been  abundant.  The  conveyance  of  malaria  by 
winds  and  at  long  distances  from  malarial  regions 
is  readily  explained  by  the  fact  that  the  Anopheles, 


I40  HOW   TO    KEEP   WELL 

which  are  ready  travelers,  are  blown  along,  bear- 
ing with  them  their  stock  of  plasmodia.  In  fact, 
few  of  the  previously  obscure  questions  now  lack 
for  an  explanation. 

In  the  light  of  our  present  knowledge,  it  may  be 
positively  stated  that  malaria  may  be  transmitted 
by  the  agency  of  mosquitoes  of  the  Anopheles 
species.  It  may  be  said  with  almost  equal  cer- 
tainty that  this  is  the  only  method  of  conveying 
the  disease.  These  facts  are  confirmed  by  many 
well-known  tests.  A  son  of  Doctor  Manson,  a 
healthy  man  who  had  never  had  malaria  nor  been 
in  a  malarious  region,  allowed  himself  to  be  bitten 
in  England  by  infected  mosquitoes  brought  from 
Italy.  In  a  few  days  he  came  down  with  a  sharp 
attack  of  malaria,  and  plasmodia,  which  were  not 
present  in  the  blood  before,  were  found  in  abund- 
ance. Men  protected  by  screens  live  in  malarious 
regions  with  impunity,  and  sleep  night  after  night 
in  localities  where  it  has  been  regarded  as  almost 
certain  death  to  remain  after  dark.  In  that 
very  dangerous  region,  the  Campania,  Doctor 
Sambron  and  a  friend  spent  the  nights  from  June 
to  September,  1900,  in  a  well-screened  hut,  and 
escaped  infection.  In  Havana,  in  the  campaign 
against  the  yellow-fever-bearing  mosquitoes,  all 
mosquitoes  were  killed  as  far  as  possible  and  their 


i^HE  Infectious  diseases       141 

breeding  places  were  destroyed.  In  1900,  the 
year  previous  to  the  mosquito  work,  there  were 
344  deaths  from  malarial  fever.  In  1901,  the 
first  year  of  the  mosquito  work,  there  were  151 
deaths,  and  in  1902  only  90.  A  battalion  of 
Japanese  troops  in  Formosa  was  protected  from 
mosquitoes  for  161  days  during  the  malarial 
season  and  entirely  escaped  the  disease.  An 
unprotected  battalion  in  the  same  place  developed 
during  that  time  259  cases  of  malaria.  These 
are  but  a  few  of  many  similar  proofs. 

The  efficacy  of  the  simple  precaution  of  screening 
has  become  so  well  known  that  it  is  being  employed 
on  a  large  scale  in  many  malarious  regions.  The 
Anopheles  bites  only  at  night.  Theoretically,  the 
methods  of  protection  are  simple.  Practically 
they  are,  in  many  regions,  very  difficult  to  carry 
out.  The  Anopheles  are  inclined  to  deposit  their 
eggs  in  natural  pools  and  puddles  which  do  not 
become  dry  quickly.  They  seem  to  select  water 
which  contains  green  water  plants,  unlike  the  Culex, 
which  is  prone  to  select  pools,  cisterns,  or  collections 
of  water  near  human  habitations. 

From  the  study  of  the  habits  of  the  Anopheles 
it  is  clear  that  the  most  feasible  method  of  exter- 
mination is  by  preventing  the  development  of  the 
larvae.     They    may    be    most    easily   reached    by 


142  HOW   TO    KEEP   WELL 

seeking  them  in  their  habitat  while  in  that  state 
of  development.  The  drainage  of  all  pools  and 
puddles,  therefore,  so  far  as  it  is  practical,  should 
be  the  first  measure  taken.  Although  the  disease- 
producing  insect  does  not  commonly  seek  tempo- 
rary collections  of  rain  water  near  houses,  such 
collections  should  not  be  permitted  to  remain. 
Bodies  of  water  which  cannot  be  drained  may  be 
made  free  of  larvae  l)y  sprinkling  the  surface  with 
petroleum  or  some  other  light  oil.  The  oil  quickly 
spreads  over  the  surface  and  prevents  the  larvae 
from  getting  access  to  the  air,  as  it  is  for  this 
necessary  purpose  that  they  come  to  the  surface. 
A  half  teaspoon  of  oil  to  a  square  yard  is  an  ample 
amount.  Fish  eat  the  larvae,  and  in  larger  bodies 
of  water  where  the  use  of  oil  is  undesirable  much 
may  be  done  in  prevention  by  stocking  the  water 
with  fish.  In  damp  and  marshy  regions  draining 
is  the  proper  measure  to  apply.  In  many  locali- 
ties simple  means  are  ample  for  the  prevention  of 
malarial  infection.  The  methods  necessary  to 
attain  success  in  this  work  are  admirably  described 
in  an  article  in  the  Century  Magazine  for  July, 
1902,  upon  the  operations  at  Oyster  Bay,  Long 
Island,  where  the  conditions  were  almost  hopeless. 
In  regions  where  such  measures  cannot  be  employed 
the  most  important  measure  is  thorough  screening 


THE    INFECTIOUS   DISEASES         143 

of  all  doors  and  windows,  with  the  additional  pre- 
caution of  mosquito  bars  for  the  beds,  for  it  is 
chiefly  at  night  that  the  mosquito  does  its  work. 
The  houses  should  be  as  high  above  ground  as 
possible,  and  the  sleeping-rooms  should  be  in  the 
upper  part  of  the  house,  for  the  Anopheles  fly  low. 
In  markedly  malarious  regions  seclusion  behind 
screens  between  sunrise  and  sunset  is  an  important 
measure.  The  female  Anopheles  hibernates,  and 
selects  for  this  purpose  the  eaves,  cracks,  and 
comers  of  outhouses  and  barns.  As  these  will  be 
the  progenitors  of  next  year's  race,  their  destruc- 
tion is  important.  Much  may  be  done  in  this 
direction  by  fumigating  rooms  and  houses  with 
sulphur,  and  applying  whitewash  to  outhouses. 

It  is  obviously  important  to  debar  the  malaria- 
bearing  mosquito  from  the  chief  and  perhaps  only 
source  of  supply — the  blood  of  a  malarial  patient. 
The  malarial  patient  is  almost  as  dangerous  to  the 
community  as  is  the  mosquito,  although  his  disease 
is  not  contagious.  Not  only  should  he  be  kept 
behind  screens  while  his  blood  contains  the  Plas- 
modium, but  he  should  be  vigorously  treated 
with  quinine.  This  should  be  given  not  alone 
for  the  good  of  the  patient,  but  as  a  means  of  pre- 
venting the  spread  of  the  disease  to  others.  It 
should  be  continued  until  the  parasite  has  disap- 


144  HOW   TO    KEEP   WELL 

peared  from  the  blood,  and  for  at  least  three  days 
in  each  week  for  six  or  eight  weeks,  to  make 
certain  that  particularly  obstinate  spores  have 
been  destroyed. 

YELLOW    FEVER 

Yellow  fever  is  an  acute,  transmissible,  infectious 
disease,  but  is  not  contagious.  It  is  characterized 
by  jaundice,  hemorrhages,  vomiting  of  dark  or 
black  matter,  and  high  fever.  It  is  prevalent  in 
the  AVest  Indies,  the  Mexican  portion  of  the  Gulf 
coast,  and  the  Guinea  coast.  In  other  regions 
of  the  tropical  Atlantic  coast  it  appears  in  periodic 
epidemics,  and  in  still  more  distant  regions  ,  in 
occasional  epidemics.  It  has  thus  appeared  as 
far  north  as  Halifax. 

A  germ  known  as  the  bacillus  ictcroidcs  was  for  a 
time  believed  by  some  observers  to  be  the  exciting 
cause,  but  this  is  not  the  fact.  It  is  probable 
that  the  specific  germ  is  not  a  bacterium,  but  a 
member  of  the  animal  kingdom,  similar  to  the 
Plasmodium  of  malaria.  In  few  other  diseases 
have  recent  investigations  so  completely  changed 
our  beliefs.  It  was  believed  for  many  years  that 
yellow  fever  was  transmitted  chiefly  by  fomites — 
that  is,  clothing,  bedding,  etc.  Although  it  had 
been  thought  by  many  that  it  was  sometimes 
transmitted    by   insects,    it   was    only    within   the 


THE    INFECTIOUS    DISEASES  145 

past  two  years  that  this  was  absolutely  demon- 
strated. It  was  at  first  supposed  that  this  was  but 
one  means  of  transmission.  It  is  now  held  by 
some  of  the  best  authorities  that  it  is  the  only 
means,  and  this  belief  seems  to  be  well  borne  out 
by  experiences  in  Havana.  Those  experiences  are 
so  remarkable  and  the  results  so  extraordinary  that 
they  are  worthy  of  record. 

The  following  facts  regarding  the  stamping  out 
of  yellow  fever  in  Havana  are  derived  from  a 
statement  recently  made  by  Doctor  W.  C.  Gorgas, 
Chief  Sanitary  Officer  of.  Havana  during  the 
American  occupation.  "  Yellow  fever  had  been 
endemic  in  Havana  for  150  years,  during  which 
time  there  had  never  been  a  month  in  which  the 
city  was  free  from  it.  At  the  time  the  Americans 
assumed  control  the  general  death  rate  was  91.03 
per  1,000  of  population.  In  1899  it  fell  to  33.67, 
and  in  the  two  following  years  to  24.40  and  21.00. 
Notwithstanding  the  improvements  made  in  the 
sanitary  condition  of  the  city,  and  the  decrease  in 
the  general  death  rate,  yellow  fever  had  only  been 
slightly  affected.     An  epidemic  occurred  in  1899. 

' '  The  belief  was  then  gaining  ground  that  it 
was  conveyed  by  mosquitoes,  and  the  evidence  was 
being  narrowed  down  to  show  that  the  Culex 
mosquito    {Stegomyia   jasciata)    was    the  offender. 


146  HOW   TO    KEEP   WELL 

Orders  were  accordingly  issued  that  every  case 
should  be  screened.  This  was  done  at  public 
expense.  Screens  were  placed  at  windows  and 
doors  within  two  hours  after  a  case  was  reported. 
A  force  of  men  was  immediately  j^ut  to  work, 
and  all  mosquitoes  in  the  house  and  vicinity  were 
killed.  At  the  same  time  a  hundred  men  were 
employed  cleaning  the  streets,  draining  the  pools, 
and  putting  oil  into  cesspools  and  all  damp  places 
that  could  not  be  drained.  Yellow  fever  began 
immediately  to  abate,  but  still  disinfection  and 
fumigation  were  continued.  It  was  found  that 
the  inconvenience  caused  by  these  latter  proced- 
ures prevented  the  reporting  of  some  cases,  and  as 
knowledge  grew  they  were  believed  to  be  unneces- 
sary. Hence,  all  disinfection  of  clothing,  bedding 
and  rooms,  and  fumigation  was  stopped,  and  the 
rigid  quarantine  of  the  patient  was  stopped.  It 
was  merely  required  that  the  patient  should  be 
reported,  his  house  placarded  and  screened,  and 
a  guard  placed  to  see  that  the  screens  were  kept 
properly  in  place.  During  the  summer  of  1901  the 
disease  rapidly  subsided,  and  the  last  case  developed 
on  September  28th."  Doctor  Gorgas,  speaking  in 
New  York  in  November,  1902,  said  that  no  case 
had  developed  in  Havana  since  that  time,  a  period 
of   fourteen  months.     For  the  ten  years  preceeding 


THE    INFECTIOUS    DISEASES         147 

1899,  the  average  number  of  deaths  from  yellow 
fever  in  Havana  had  been  410,  with  a  maximum 
of  1,175  in  1896.  In  1 90 1  there  were  five  deaths 
before  September,  notwithstanding  the  fact  that 
there  were  more  non-immunes  in  the  city  than 
ever  before. 

It  is  known  tliat  infected  mosquitoes  may  survive 
and  continue  dangerous  for  long  periods  of  time — 
sufficient,  indeed,  to  account  for  their  carrying  the 
disease  from  place  to  place.  They  may  thus  take 
an  ocean  voyage  and  arrive  vigorous  and  well  at 
their  destination.  In  thus  obliterating  the  chief 
source  from  which  yellow  fever  is  periodically 
imported  into  this  country,  the  saving  in  money 
"and  human  life  to  the  United  States  will  in  a  few 
years  more  than  equal  the  money  and  life  expended 
in  the  war  with  Spain.  The  epidemic  of  1878 
cost  this  country  fully  $100,000,000.  As  Rio 
Janeiro  is  now  the  only  endemic  centre  on  this 
continent  from  which  yellow  fever  is  spread  to 
other  places,  it  is  reasonable  to  expect  that  the 
disease  will  soon  be  but  a  memory  of  the  past. 

ASIATIC     CHOLERA 

Cholera  is  an  infectious,  transmissible,  but  not 
contagious  disease,  characterized  by  fever,  violent 
vomiting  and  purging,  and  rapid  collapse.  It 
has  for    ages   been    endemic    in    India,    whence  it 


148  HOW   TO    KEEP   WELL 

extends  at  intervals  in  more  or  less  widespread 
epidemics.  Its  excursions  out  of  India  have  been 
strikingly  similar.  The  western  invasions  have 
taken  three  routes,  more  than  one  at  a  time  being 
sometimes  utilized.  The  first  of  these  routes  is 
through  Persia  and  central  Asia  to  Russia;  the 
second,  by  the  Persian  Gulf  through  Arabia  and 
Turkey  to  Constantinople  and  up  the  Danube; 
the  third,  by  way  of  the  Red  Sea  to  Aden  and 
Mecca  and  thence  to  Egypt  and  the  countries  of 
the  west.  The  route  by  Mecca  is  particularly 
dangerous.  It  is  brought  by  the  pilgrims  to  that 
sacred  city,  and  is  distributed  broadcast  at  the 
sacred  well  and  other  holy  places,  where  religious 
bigotry  prevents  sanitary  regulations.  The  return-- 
ing  pilgrims  thus  scatter  it  through  the  Levantine 
and  Egyptian  cities.  From  these  regions  it  is  but 
a  step  to  Europe  and  America. 

During  the  nineteenth  century  there  were  seven 
distinct  invasions  of  Europe.  The  last,  which 
occurred  in  1891,  was  particularly  ominous  because 
of  the  unprecedented  rapidity  with  which  the 
disease  traveled.  This,  of  course,  was  due  to 
increased  facility  of  human  intercommunication, 
and  is  a  warning  that  each  future  invasion  will  for 
that  reason  be  more  difficult  to  control.  The  last 
appearance  of  the   disease   in  the   United   States 


THE    INFECTIOUS    DISEAvSES  149 

was  in  1873.  Cases  reached  New  York  in  1892, 
but  with  the  exception  of  three  or  four  doubtful 
cases,  it  was  stopped  at  quarantine.  As  the  last 
two  European  invasions  occurred  at  intervals  of 
twelve  years,  and  as  the  longest  interval  during 
the  past  century  was  fifteen  years,  it  is  not  unrea- 
sonable to  expect  that  another  western  invasion 
will  occur  in  the  not  distant  future.  The  epidemics 
in  Egypt  and  the  Philippines  give  evidence,  in 
fact,  that  the  disease  is  again  bestirring  itself. 
On  July  25th  it  broke  out  in  Astrakhan,  but  the 
number  of  cases  was  not  large.  Epidemics  usually 
occur  in  the  warm  months,  and  in  northern  latitudes 
disappear  during  the  winter.  This,  however,  is 
not  an  invariable  rule. 

Cholera  is  caused  by  the  bacterium  known  as  the 
spirillum  cJioleiw,  more  commonly  called  the  comma 
bacillus,  because  of  its  resemblance  to  that  punctu- 
ation mark.  It  was  discovered  in  1884  by  Koch, 
who  had  been  sent  to  India  by  the  German  Govern- 
ment. It  is  a  germ  presenting  many  peculiarities. 
It  belongs  to  the  facultative  group  of  bacteria,  and 
develops  in  a  suitable  medium  outside  the  body 
almost  as  well  as  in  the  intestinal  canal.  It  will 
live  for  months  in  a  moist  medium,  but  quickly 
perishes  when  dried.  This  is  an  important  fact. 
When  infected  secretions  are  dried  in  a  thin  laver, 


ISO  HOW   TO    KEEP   WELL 

the  spirillum  loses  its  vitality  after  two  hours. 
In  thicker  layers  and  on  threads  and  cloth  it  lives 
much  longer.  It  is  not  exhaled  by  the  breath, 
and  cannot  circulate  in  the  atmosphere  in  a  moist 
condition.  The  disease  is  not,  therefore,  conveyed 
by  the  air,  and  is  not  contagious.  There  is  no 
danger  from  letters  which  come  from  a  region 
where  cholera  prevails,  unless  they  have  been 
actually  soiled  by  choleraic  discharges.  Even 
in  that  case  the  thorough  drying  they  undergo 
would  probably  destroy  the  germs. 

Cholera  is  only  contracted  by  taking  the  germs 
into  the  stomach.  They  may  be  carried  directly 
to  the  mouth  by  the  hand  or  unclean  dishes,  but 
they  more  frequently  enter  with  contaminated 
food  or  water.  With  a  pure  water  supply  epidemics 
rarely  become  uncontrollable.  The  germ  is  not 
affected  by  cold,  l)ut  is  killed  by  heat,  so  that 
thorough  cooking  is  a  sure  safeguard.  It  is  sensi- 
tive to  acids,  and  is  destroyed  by  the  acid  secretions 
of  the  stomacli  when  they  are  in  a  normal  condition. 
The  administration  of  acids  after  eating  is  there- 
fore rational  preventive  treatment.  The  seat  of 
activity  of  the  sprillum  is  the  intestinal  canal.  It 
is  conveyed  from  the  patient  only  in  the  intestinal 
discharges.  In  rare  instances  it  has  been  found 
in  vomited  matter.     It  is  easy  to  understand  why 


THE    INFECTIOUS    DISEASES  151 

the  disease  prevails  among  the  filthy  inmates  of 
the  steerage  and  rarely  attacks  the  cleanly  passen- 
gers of  the  cabin;  why  nurses  and  physicians  may 
come  in  daily  contact  with  cholera  in  well-regulated 
hospitals  and  escape  infection.  They  keep  the 
patients  scrupulously  clean,  and  immediately 
disinfect  and  remove  the  discharges;  they  use 
water  which  has  been  boiled ;  they  eat  clean  cooked 
food  from  clean  dishes;  they  cleanse  the  hands 
frequently  and  keep  them  away  from  the  mouth. 

The  importance  of  a  pure  water  supply  for  cities 
was  graphically  shown  by  the  experience  in  1892 
of  Hamburg  and  Altona,  two  cities  lying  side  by 
side.  Both  take  their  water  supply  from  the 
River  Elbe.  Altona  passed  it  through  sand  filters 
before  allowing  it  to  enter  the  city.  There  were 
34  cases  of  cholera  to  each  10,000  of  population, 
and  many  of  these  were  brought  over  from  the 
adjacent  infected  regions  of  Hamburg.-  Hamburg 
used  unfiltered  water,  and  during  the  same  time 
there  were  246  cases  to  the  10,000  of  population. 

The  only  portal  of  entrance  for  the  comma 
bacillus  is  the  alimentary  tract.  Ernest  Hart's 
aphorism  applies  equally  to  cholera  and  typhoid 
fever:  "You  can  eat  cholera  and  you  can  drink 
cholera,  but  you  cannot  catch  cholera."  Preven- 
tion may  be  summed  up  in  one  word — cleanliness. 


152  HOW   TO    KEEP   WELL 

Improper  food  alone  can  never  cause  cholera,  but  by 
disturbing  digestion  may  predispose  it.  Good  gen- 
eral health  and  perfect  digestion  confer  immunity 
to  a  very  appreciable  degree.  It  is  particularly 
prone  to  attack  the  intemperate  and  those  debili- 
tated by  bad  surroundings  and  want  of  food. 
When  the  disease  is  prevalent,  nothing  but  freshly 
cooked  food  should  be  used,  and  water  and  milk 
should  be  boiled.  The  hands  should  be  washed 
and  disinfected  before  eating.  Flies  and  other 
insects  should  be  prevented  from  gaining  access 
to  the  food.  As  cholera  is  spread  much  the  same 
as  typhoid  fever,  it  should  receive  the  same  pre- 
cautions and  care. 

The  preventive  inoculation  of  Haffkine  certainly 
shows  encouraging  results.  Among  about  200,000 
cases  inoculated,  there  were  but  1-19  as  many  cases 
and  I -1 7  as  many  deaths  as  among  those  not 
receiving  the  treatment. 

As  the  period  of  incubation  is  rarely  more  than 
five  days,  proper  precautions  at  quarantine  render  it 
possible  to  prevent  the  introduction  of  cholera 
into  America.  A  person  infected  before  leaving 
a  European  port  would  develop  symptoms  before 
his  arrival  here.  In  case  of  a  general  European 
epidemic,  however,  it  would  require  the  inost 
extreme  caution  to  prevent  its  gaining  a  foothold 


THE    INFECTIOUS    DISEASES  153 

in  this  country,  for  mild  cases  might  slip  past  the 
most  watchful  health  officers.  The  denunciations 
of  the  Health  Office  of  New  York  which  kept  it  out 
in  1892  would  be  mild  to  what  would  fall  upon 
one  who  should  let  it  pass. 

THE    PLAGUE 

The  plague,  next  to  leprosy,  was  the  most  promi- 
nent disease  in  the  history  of  the  past.  It  is 
variously  known  as  bubonic  plague,  Oriental 
plague,  Justinian  plague,  and  black  death.  The 
latter  name  is  given  because  of  extensive  hemor- 
rhages which  occur  under  the  skin.  It  is  charac- 
terized by  high  fever,  inflammation  of  the  lym- 
phatic glands,  hemorrhages,  and  brain  symptoms. 
Its  mortality  is  high.  It  is  a  filth  disease  in  the 
sense  that  its  occurrence  and  dissemination  are 
accelerated  by  overcrowding,  filth,  poor  food,  and 
intemperance.  No  one  of  these,  however,  nor  a 
combination  of  them  all,  will  cause  the  disease 
without  the  presence  of  the  specific  bacillus. 

Its  home  for  centuries  was  in  northern  Africa, 
from  which  at  intervals  it  issued  forth  in  world-wide 
epidemics.  One  of  the  first  of  these  great  epi- 
demics occurred  in  the  reign  of  Justinian,  in  the 
sixth  century,  from  which  it  derived  one  of  its 
names.  The  black  death  of  the  fourteenth  century 
was  one  of  the  most  dreadful  of  its  visitations  to 


154  HOW   TO    KEEP    WELL 

Europe.  During  that  epidemic  it  was  estimated 
that  it  destroyed  25,000,000  people,  a  quarter  of 
the  entire  population  of  western  Europe.  In 
those  early  times  diseases  were  poorly  differentiated, 
and  it  is  probable  that  during  some  of  these  worst 
epidemics  the  plague  was  accompanied  by  malig- 
nant typhus  fever  and  perhaps  the  malignant 
forms  of  other  contagious  diseases.  The  unsani- 
tary modes  of  life  of  those  early  times  would  make 
their  occurrence  quite  possible.  During  the  Great 
Plague  of  London  in  1665  there  were  70,000  deaths 
in  a  single  year  in  a  population  of  less  than  a 
million.  Two-thirds  of  the  people  fled;  the  panic 
and  terror  can  hardly  be  comprehended. 

The  plague  appeared  at  Hongkong  in  1894. 
From  that  city  it  spread  rapidly  toward  the  East, 
and  has  since  been  epidemic  in  India.  Within 
nine  months  after  its  appearance  in  Bombay  it 
caused  20,000  deaths.  It  has  extended  to  other 
parts  of  the  world  in  localized  epidemics.  A  few 
cases  occurred  in  Glasgow  in  1900  after  an  absence 
from  the  British  Islands  of  more  than  200  years.  It 
reached  quarantine  in  New  York  in  1899,  but  was 
there  stopped.  There  has  been  an  epidemic 
among  the  Chinese  in  San  Francisco,  59  cases 
having  occurred  up  to  July  15,  1902.  The  occur- 
rence   of    so    many    cases    was    unnecessary    and 


THE    INFECTIOUS   DLSEASEvS  155 

unjustifiable.  The  whole  country  has  a  just 
grievance  against  the  health  authorities  of  that 
city,  who  long  refused  to  acknowledge  its  presence 
and  take  the  necessary  precautions  against  its 
spread  to  other  places. 

Sanitary  conditions  have  so  large  an  influence 
upon  the  spread  of  the  plague  that  it  is  doubtful 
whether  it  could  reach  very  formidable  proportions 
in  this  country.  Still  it  might  become  a  very 
grave  danger  were  it  to  occur  in  tenement  popula- 
tions. At  Hongkong  the  death  rate  among  the 
Chinese  was  93  per  cent.',  among  the  Japanese  60 
per  cent.,  and  the  Europeans  18  per  cent.  These 
great  differences  are  probably  not  due  to  racial 
peculiarities,  but  rather  to  social  customs.  The 
wide  extent  as  well  as  the  mortality  of  epidemics 
among  the  Oriental  races  is  largely  due  to  their 
religious  and  social  ideas.  Family  ties  are  so 
close  and  sacred  that  the  removal  of  the  sick  is 
permitted  only  by  force,  and  isolation  is  alwa3^s 
difficult,  and  often  impossible.  Certain  of  their 
religious  rites  in  connection  with  the  disposal  of 
the  dead  lead  to  frequent  concealment  of  illness. 

These  factors  are  ver}^  serious  obstacles  to  the 
sanitary  control  of  epidemic  diseases  of  all  kinds 
in  the  East.  With  communication  between  the 
nations   becoming  closer    vear    bv    vear,   and    the 


156  HOW   TO    KEEP   WELL 

world  thus  becoming  smaller,  questions  of  this 
character  become  of  more  and  more  importance 
to  cleanly  and  hygienic  nations.  The  manner  in 
which  the  British  Government  restricts  these 
epidemics  in  the  face  of  almost  unsurmountable 
obstacles,  and  steadily  improves  the  sanitary 
conditions  of  its  possessions,  places  the  civilized 
world  under  a  debt  of  obligation.  The  success  of 
the  British  in  such  work,  and  the  recent  success  of 
the  Americans  in  cleaning  out  plaguq  spots,  are 
among  the  strongest  arguments  for  those  who  hold 
that  the  control  of  the  less  civilized  by  the  more 
civilized  nations  is  justifiable.  Certain  it  is  that 
many  of  these  nations  will  not  keep  themselves 
clean  of  their  own  accord,  nor  cease  to  be  a  menace 
to  those  with  whom  they  come  in  contact.  Unless 
some  power  be  invoked  to  compel  them  to  keep 
clean,  one  of  two  results  must  follow:  either  the 
modern  tendency  to  trade  and  commerce  must  be 
restricted,  or  the  western  nations  must  be  content 
to  suffer  from  periodical  visitations  of  preventable 
filth  diseases  like  yellow  fever,  cholera,  and  the 
plague. 

The  germ  of  the  plague  is  known  as  the  bacillus 
pestis.  It  is  destroyed  by  drying  in  four  days, 
and  by  sunlight  in  from  three  to  four  hours.  It  is 
killed  by  water  below  the  boiling  point,  and  by  a 


THE    INFECTIOUS   DISEASES  157 

comparatively  weak  solution  of  carbolic  acid. 
Rats,  mice,  sheep,  dogs,  and  several  other  animals 
are  susceptible  to  the  disease,  and  the  bacillus 
may  be  readily  carried  by  beetles  and  flies.  The 
germ  exists  in  the  soil.  When  introduced  into 
unclean  and  filthy  places  it  readily  develops  and 
becomes  fixed.  Almost  without  exception  plague 
centres  possess  a  soil  polluted  with  decomposing 
animal  matter.  It  is  a  fact  well  known  that,  pre- 
ceding an  epidemic  of  plague,  it  has  also  been 
epidemic  among  rats  and  mice.  Living  close  to 
the  soil,  they  readily  become  infected,  and  being 
vigorous  travelers,  they  spread  infection  broad- 
cast. This  is  so  well  known  that  ships  entering 
infected  ports  are  kept  from  contact  with  the 
docks,  and  guards  to  prevent  the  entrance  of  rats 
are  placed  upon  the  cables  and  stays. 

The  contagion  of  plague  may  be  conveyed  by 
means  of  infected  clothing  or  any  other  article 
that  has  been  used  and  soiled  by  the  patient.  It 
is  doubtful  whether  it  is  spread  by  means  of 
infected  water,  and  it  is  also  doubtful  whether  it 
can  be  conveyed  through  the  air.  Those  in 
attendance  upon  the  sick,  who  use  proper  precau- 
tion, rarely  contract  the  disease.  Prevention  con- 
sists of  absolute  isolation,  and  the  employment  of 
all  those  measures  of  disinfection  and  hygienic  care 


158  HOW   TO    KEEP   WELL 

which  in  civilized  countries  it  is  customary  to 
bestow  upon  diseases  of  such  nature.  Vermin  of 
all  kinds  should  be  sought  for  and  destroyed. 
Particularly  should  rats  and  mice  be  caught  and 
their  bodies  burned.  Insects  should  be  destroyed, 
and  the  room  in  which  the  patient  lies  should  be 
screened. 

Two  forms  of  serum  treatment  are  being  used 
and  carefully  watched.  The  preventive  inocula- 
tion of  Haffkine  is  certainly  encouraging  in  the 
results  reported.  It  is  designed  to  be  given  to 
those  who  are  likely  to  contract  the  disease  from 
known  exposure,  but  have  not  as  yet  shown 
symptoms.  The  other  is  the  antitoxin  of  Yersin. 
It  is  prepared  in  a  manner  similar  to  that  of  pre- 
paring the  diphtheria  antitoxin.  Animals  to 
which  this  antitoxin  has  been  given  are  unaffected 
by  an  otherwise  fatal  dose  of  pest  toxin.  Its  effect 
upon  the  human  subject  suffering  from  the  disease 
is  not  marked,  however,  for  the  same  reasons, 
probably,  as  are  given  for  the  slight  action  of  the 
tetanus  antitoxin. 

TYPHUS    FEVER 

Typhus  fever,  also  known  as  camp  fever,  ship 
fever,  and  jail  fever,  is  an  acute,  contagious  dis- 
ease, characterized  by  very  high  fever  and  extreme 
depression    of    the    vital    powers.     It    terminates 


THE    INFECTIOUS   DISEASES         159 

usually  in  fatal  cases  by  crisis  in  aVjout  two 
weeks.  There  is  no  other  disease  which  numbers 
proportionately  so  many  victims  among  nurses 
and  physicians.  Until  the  middle  of  the  nine- 
teenth century  it  was  one  of  the  great  epidemic 
diseases  of  the  world.  "The  history  of  typhus 
for  three  centuries  would  be  the  history  of  Europe," 
says  Murchison.  Its  gradual  disappearance  is  one 
of  the  triumphs  of  modern  sanitation.  Its  last 
decided  epidemic  in  Europe  was  during  the  Turco- 
Russian  war  of  1877,  The  last  outbreak  in  this 
country  was  in  New  York  in  1881-82,  when  735 
cases  occurred. 

The  most  important  predisposing  cause  of  typhus 
fever  is  destitution  and  the  misery  which  commonly 
results  from  overcrowding  and  filth.  The  mortality 
is  not  high  in  young  adults,  but  during  and  after 
middle  life  it  is  50  per  cent,  or  more.  Endemic 
centres  have  gradually  been  contracted  until  very 
few  remain.  They  are  of  small  area  and  are  limited 
to  Ireland,  Russia,  and  Italy.  No  other  disease 
is  so  readily  restricted  by  good  sanitary  and 
hygienic  conditions,  and  these  are  the  chief  meas- 
ures of  prevention.  Under  the  improved  sanitary 
conditions  of  recent  years  in  all  civilized  countries, 
it  is  doubtful  if  ever  again  typhus  fever  develops  a 
widespread  epidemic. 


i6o  HOW   TO    KEEP   WELL 

LEPROSY 

Leprosy  is  a  chronic,  non-contagious,  infectious 
disease,  caused  by  the  bacillus  leprcB,  a  germ 
which  in  some  respects  resembles  the  bacillus 
tuberculosis.  Leprosy  appears  in  two  forms — 
the  nodular,  in  which  thick  nodules  appear  in  the 
skin  of  the  face  and  body,  and  the  anesthetic,  in 
which  the  sensory  nerves  are  the  first  involved. 
The  latter  is  characterized  by  a  dry,  fiat  eruption 
which  becomes  dirty  white  in  colour.  In  modern 
times  a  leper  "white  as  snow"  is  rarely,  if  ever, 
seen.  In  the  later  stages,  the  two  forms  are 
sometimes  seen  together,  and  ulcerations  occur 
in  all  cases.  The  anesthetic  variety  is  more 
commonly  seen  in  warm  climates,  the  nodular  in 
cold.  It  is  very  slow  in  its  progress,  and  always 
terminates  fatally. 

Leprosy  is  one  of  the  oldest  of  known  diseases. 
It  is  most  prevalent  in  India,  where  it  is  estimated 
that  there  are  a  quarter  of  a  million  cases.  It 
prevailed  in  Europe  during  the  Middle  Ages,  but 
gradually  declined  during  the  sixteenth  century, 
and  is  now  rare  except  in  Norway.  It  is  probable 
that  the  rigid  isolation  enforced  in  Europe  had 
much  to  do  with  its  disappearance.  In  this  country 
it  occurs  chiefly  in  three  localities,  Louisiana, 
California,    and    Minnesota.     The   numbers,    how- 


THE    INFECTIOUS    DISEASES  i6i 

ever,  are  not  large  in  either  place.  It  has  been 
known  in  the  Gulf  States  since  1785,  and  is  now 
slowly  increasing.  In  California  it  is  confined  to 
the  Chinese,  but  one  white  man  being  known  to 
have  contracted  it.  In  the  Northwest  it  is  con- 
fined to  the  Norwegians,  170  lepers  having  gone 
there  as  immigrants.  It  is  steadily  decreasing, 
and  it  is  believed  that  there  were  but  thirty-seven 
cases  in  1900.  No  native  American  is  known 
to  have  contracted  it,  and  there  are  probably 
less  than  500  cases  at  present  in  the  United  States. 
We  have,  however,  acquired  two  celebrated 
leper  colonies,  those  of  Hawaii  and  the  Philippines. 
The  disease  has,  therefore,  become  of  renewed 
interest  to  our  sanitarians. 

Leprosy  is  spread  only  by  intimate  contact.  It 
is  doubtful  whether  it  is  contagious,  and,  if  so,  a 
special  predisposition  is  required  for  its  trans- 
mission. Heredity  is  certainly  an  active  factor 
in  its  occurrence.  The  marriage  of  lepers  should, 
if  possible,  be  prevented.  The  English  leprosy 
commission  considers  compulsory  segregation  as 
unnecessary,  while  the  leprosy  conference  at 
Berlin  in  1897  held  that  segregation  was  the  best 
means  of  preventing  its  spread.  It  is  a  fact  that 
where  the  segregation  of  lepers  has  been  enforced, 
the  number  of  cases  in  that  locality  has  always 


i62  HOW   TO    KEEP    WELL 

decreased.  It  would  be  fortunate  if  they  could 
be  colonized  in  some  agricultural  district,  where 
they  could  live  comfortably  and  where  hospitals 
could  be  established  for  their  care  in  the  later 
stages. 

DENGUE 

Dengue,  or  breakbone  fever,  is  a  disease  of 
tropical  or  subtropical  countries,  characterized  by 
sudden  onset,  high  fever,  and  excessive  pains  in 
the  joints  and  muscles.  It  is  short  in  its  duration, 
and  is  sometimes  known  as  three-day  fever.  It  is 
a  disease  of  low-lying  regions,  chiefly  those  along 
the  coast,  and  is  most  common  in  overcrowded 
and  unsanitary  towns.  It  is  rarely,  if  ever,  seen 
in  high  altitudes  or  at  great  distances  from  the 
sea  coast.  An  extensive  epidemic  occurred  in 
1828  chiefly  in  the  Gulf  States,  and  since  that 
time  there  have  been  four  widespread  epidemics. 
The  disease  is  remarkable  for  the  rapidity  of  its 
spread  and  the  large  numbers  who  suffer,  it  being 
approached  in  this  regard  only  by  epidemic  in- 
fluenza. Another  peculiarity  is  the  fact  that 
it  rarely  proves  fatal,  while  the  symptoms  are  of 
extreme  severity. 

A  germ  has  been  discovered  which  is  claimed  to 
be  the  exciting  cause.  The  truth  of  this  has, 
however,  not  been  demonstrated.     Notwithstand- 


THE   INFECTIOUS   DISEASES         163 

ing  its  rapid  spread,  its  contagiousness  has  been 
denied  by  some.  It  has  been  known  to  occur  in 
locahties  where  it  could  not  apparently  have 
been  conveyed  by  contagion.  The  theory  of 
spontaneous  generation  cannot  be  held,  but  it 
seems  possible  that  conditions  may  arise  that 
will  call  germs  into  activity  in  various  places  at  the 
same  time.  It  is  well  known  that,  after  the  sub- 
sidence of  an  epidemic,  the  disease  will  remain 
endemic  in  certain  localities  for  some  time.  It 
is  a  characteristic  of  many  infectious  diseases 
that  the  germs  may  at  times  lie  in  a  comparatively 
inactive  stage,  to  wake  suddenly  into  activity 
with  a  tendency  to  spread  and  cause  epidemics. 
There  are  apparently  no  preventive  measures 
against  dengue  which  can  be  adopted  by  ordinary 
individuals  who  continue  their  usual  avocations. 

HYDROPHOBIA 

Rabies,  or  hydrophobia,  is  an  acute,  infectious 
disease,  communicated  from  animals  to  animals, 
and  from  animals  to  man.  In  animals  the  disease 
is  commonly  known  as  rabies,  in  man  as  hydro- 
phobia. The  latter  term  means  fear  of  water,  and 
is  used,  not  because  the  patient  fears  water  in  itself, 
but  because  of  the  dread  of  the  spasms  of  the 
muscles  of  deglutition  upon  efforts  to  swallow  it. 
The  virus  is  contained  in  the  saliva,  and  its  trans- 


i64  HOW   TO    KEEP   WELL 

mission  is  virtually  an  inoculation.  Rabies  is 
variable  in  its  distribution.  In  Russia,  England, 
and  France  it  is  comparatively  common;  in  this 
country  it  is  rare;  in  portions  of  Germany,  where 
all  dogs  are  muzzled,  it  does  not  occur.  Cats  are 
subject  to  rabies,  as  are  also  wolves,  skunks,  and 
jackals.  The  bites  of  the  wolf  and  skunk  are 
particularly  virulent. 

In  dogs,  the  period  of  incubation  is  from  ten 
to  fifteen  days.  The  first  symptoms  are  usually 
sullenness,  disinclination  for  company,  and  marked 
alterations  in  temperament.  The  dog  develops  a 
tendency  to  roam,  and  trots  about  for  hours  with 
his  head  depressed,  snapping  at  all  objects  that 
come  in  his  way.  It  is  then  that  he  is  particularly 
dangerous  to  others.  This  stage  is  followed  by  one 
of  excitability  or  of  paralysis. 

In  man,  the  first  symptoms  are  irritation  about 
the  bite,  irritability  of  temper,  sleeplessness, 
headache,  and  vague  pains.  This  is  followed 
by  a  stage  of  excitement  which  lasts  from  one  to 
three  days  and  passes  into  the  stage  of  paralysis. 
The  patient  becomes  quiet,  and  the  spasms  which 
marked  the  preceding  stage  subside,  and  death 
occurs  by  syncope. 

Prevention  consists  in  the  destruction  of  all 
vagrant  dogs,  the  registering  and  taxing  of  dogs, 


THE    INFECTIOUS    DISEASES  165 

and  the  muzzling  of  all  dogs.  These  measures, 
together  with  the  isolation  or  destruction  of  all 
animals  who  have  been  bitten  by  suspicious  dogS; 
have  repeatedly  resulted  in  the  disappearance  of 
the  disease  where  it  has  been  epidemic.  In 
Prussia,  for  example,  such  preventive  measures 
have  reduced  the  deaths  from  hydrophobia  in 
human  beings  from  a  yearly  average  of  166  to  4.5. 
In  eighteen  months  after  the  muzzling  law  was 
adopted  in  Vienna,  rabies,  which  had  before 
been  prevalent,  completely  disappeared.  A  muz- 
zling law  was  passed  in  England  in  1890.  For 
three  years  before  that  the  deaths  from  hydro- 
phobia had  averaged  229  yearly.  They  at  once 
fell  to  ;^8.  The  law  caused  annoyance  to  the 
owners  of  dogs,  and  was  repealed.  The  deaths 
rose  in  the  next  two  years  to  672.  It  was  again 
enacted,  and  they  fell  to  17,  and  the  next  year  to  9, 
and  in  1900  there  were  none. 

The  bites  of  animals  should  be  thoroughly 
cauterized  at  the  earliest  possible  moment  with 
concentrated  carbolic  acid.  This  is  more  efficient 
in  its  action  than  is  the  lunar  caustic  or  nitrate 
of  silver  commonly  employed,  and  does  not  leave 
such  unsightly  scars. 

The  preventive  inoculation  of  Pasteur  certainly 
produces  decided  results,  though  it  does  not  appear 


i66  HOW   TO    KEEP   WELL 

that  it  is  an  absolute  preventive.  The  average 
mortahty  of  all  classes  of  bites  from  rabid  animals 
is  about  15  per  cent.,  while  the  mortality  of  those 
bitten  on  the  head,  face,  and  hands  ranges  from 
60  to  80  per  cent.  Statistics  compiled  by  Henii 
Pottevin  show  the  striking  reductions  in  these 
death  rates  that  have  been  accomplished  in  the 
Pasteur  Institute  of  Paris.  In  1886,  2,671  persons 
who  had  been  bitten  by  supposed  rabid  animals 
were  treated,  with  a  mortality  of  .94.  This  rate 
steadily  diminished  during  the  next  seven  years, 
and  for  the  last  five  years  has  ranged  from  .22  to 
.50  per  cent.  The  subject  is  further  discussed 
in  the  chapter  on  antitoxins,  but  as  there  is  doubt 
in  the  minds  of  many  regarding  the  efhciency  of 
Pasteur's  treatment,  the  following  quotation  may 
be  given.  It  is  from  a  report  made  to  Parliament 
in  1887,  signed  by  such  men  as  Lister,  Paget, 
Brunton,  Quain,  and  Roscoe:  "It  may  be  deemed 
certain  that  M.  Pasteur  has  discovered  a  method 
of  protection  from  rabies  comparable  with  that 
which  vaccination  affords  against  infection  from 
smallpox." 

THE    SUMMER    DISEASES    OF    CHILDREN 

The  diarrheal  diseases  which  occur  during  the 
summer  months  are  among  the  most  fruitful 
causes  of  infant  mortality.     While  these   diseases 


THE    INFECTIOUS    DISEASES  167 

are  more  prevalent,  and  work  the  greatest  havoc 
in  large  cities,  they  are  by  no  means  confined  to 
them.  In  New  York  City  they  begin  to  appear 
during  the  latter  part  of  June,  reach  their  maximum 
in  July,  and  gradually  subside  through  August  and 
September,  and  almost  disappear  in  October. 

Until  comparatively  recent  times  these  diseases 
were  largely  attributed  to  two  causes — teething 
and  hot  weather.  The  teething  theor}^  seems  to 
be  very  firmly  fixed  in  the  popular  mind.  Until  it 
was  eradicated  from  the  mind  of  the  medical  pro- 
fession, no  progress  whatever  was  made  in  the  con- 
trol and  treatment  of  these  disorders.  To  say 
that  teething  never  causes  digestive  disturbance 
is  to  go  to  an  extreme,  but  to  suppose  that  it  has 
more  than  a  predisposing  effect  in  producing  these 
serious  forms  of  summer  disease  is  to  make  a 
serious  error.  It  is  difficult  to  understand  why 
the  teeth  should  produce  such  disastrous  results 
at  one  season  of  the  year  and  not  another.  To 
suppose  that  diarrhea  is  a  necessary  accompani- 
ment of  teething,  and  that  a  child  is  in  fact  better 
for  it,  is  an  error  which  has  cost  thousands  of  lives. 
Looseness  of  an  infant's  bowels,  if  the  character 
of  the  movements  continues  normal,  may  do  no 
harm  for  short  periods  of  time;  but  diarrhea  in 
which  the  character  of  the  movements  is  changed 


i68  HOW   TO    KEEP    WELL 

is  never  beneficial,  but  always  detrimental.  Even 
if  the  number  of  passages  is  small,  they  should 
receive  attention,  because  serious  conditions  may 
develop  at  any  time.  Diarrhea  miay  result  from 
acute  indigestion.  In  such  cases  a  laxative  to 
remove  the  fermenting  matter  is  frequently  all 
that  is  necessary  for  cure.  It  is  not  that  form  of 
disease,  however,  that  is  commonly  known  as 
summer  diarrhea,  which  is  an  infection  and  the 
result  of  bacterial  action.  This  subject  has  received 
much  study  from  bacteriologists,  both  in  this 
country  and  abroad.  They  have  not  discovered 
a  particular  germ  as  the  sole  cause  of  the  various 
forms  of  summer  diarrhea,  but  there  seems  to  be 
little  doubt  that  they  may  result  from  several 
different  forms  of  germ  life.  This  is  quite  in 
accord  with  the  fact  that  the  disease  appears  under 
a  variety  of  forms  and  types.  The  discovery  of 
a  specific  germ,  recently  claimed  by  Duval  and 
Bassett,  to  which  much  sensational  notice  has  been 
given  by  the  daily  papers,  has  not  at  the  present 
writing  been  verified  by  other  observers. 

The  question  arises  as  to  why  bacteria,  if  they 
be  the  cause  of  the  disease,  are  so  active  at  one 
season  and  so  inactive  at  another.  It  has  been 
found  that  these  diseases  do  not  prevail  in  epi- 
demic form  until  the  mean  daily  temperature  has 


THE    INFECTIOUS    DISEASES  169 

reached  61°  F.  A  few  days  after  this  temperature 
has  been  attained,  the  summer  diarrhea  begins, 
and  the  city  dispensaries  are  overrun  with  patients. 
Heated  terms  of  extraordinary  duration  or  severity 
are  marked  by  a  few  more  cases,  due  to  the  pros- 
tration which  naturally  follows  such  periods.  Still 
the  number  of  cases  is  not  in  proportion  to  the 
temperature  after  this  mean  heat  of  61°  has  been 
reached.  Tliis  means  that  the  bacteria  which 
cause  these  diseases  begin  to  thrive  and  develop 
at  61°.  Late  June  and  early  July  are  marked  by  a 
particularly  large  number  of  cases  because  the 
weak  and  puny  infants  are  the  first  to  succumb. 
They  are  only  waiting  for  the  first  hot  days,  with 
the  resulting  milk  infection,  to  be  seized  with 
diarrhea.  Having  little  resisting  power,  they  are 
unable  to  survive  the  attack.  It  is  but  the  work- 
ing of  the  inexorable  law  of  the  survival  of  the 
fittest.  So  definite  is  the  onset  of  these  epidemics 
of  infectious  diarrhea  that  frequently  about  the 
twentieth  of  June  half  a  dozen  cases  appear  at  a 
dispensary  on  the  first  day.  Thereafter  until 
October  there  is  never  a  day  in  which  the  disease 
is  absent. 

Age  is  an  important  predisposing  cause.  Some 
years  ago  I  found,  in  investigating  3,000  cases,  that 
four-fifths  of  them  occurred  during  the  first  two 


lyo  HOW   TO   KEEP  WELL 

years  of  life,  and  that  the  greatest  susceptibility 
was  between  six  and  eighteen  months.  The  sur- 
roundings are  an  element  in  the  causation  because 
the  disease  results  from  contamination  of  the  food. 
The  constitution  of  the  infant  is  also  a  factor,  the 
weak  and  the  marasmic  being  the  first  to  be  attacked 
and  the  first  to  succumb.  Teething  should  be 
given  a  place  as  a  predisposing  cause,  but  it  is  a 
very  minor  one,  and  in  most  children  it  is  abso- 
lutely inactive.  The  food  and  methods  of  feeding 
may  be  very  potent  causes.  Of  1,943  fatal  cases 
investigated  by  Doctor  Holt,  only  3  per  cent,  were 
exclusively  breast-fed.  Among  the  well-to-do, 
serious  diarrheal  diseases  in  nursing  infants  is 
extremely  rare,  and  fatal  cases  are  almost  unknown. 
All  these  facts  lead  to  the  belief,  if  other  demon- 
strations were  not  at  hand,  that  the  summer 
diseases  of  children  are  due  to  bacteria  which  enter 
the  system  through  artificial  food.  Three  of  the 
most  important  predisposing  causes  are  overfeed" 
ing,  too  frequent  feeding,  and  the  habitual  use  of 
improper  food.  These  combine  to  produce  chronic 
indigestion,  the  most  important  of  all  the  predis- 
posing causes  of  diarrhea.  If  to  these  conditions 
are  added  a  food  which  contains  either  poison- 
producing  bacteria  or  the  poison  that  they  already 
have  produced,  we  have  all  the  elements  necessary 


THE    INFECTIOUS   DISEASES         171 

for    generating    an    acute    infectious    disease    of 
diarrheal  nature. 

The  exciting  or  immediate  causes  of  diarrhea 
are  two  in  number,  and  have  to  do  with  bacteria. 
In  the  first,  bacteria  are  introduced  into  the 
system  with  the  food.  There  they  elaborate  their 
toxin  or  ptomain,  and  a  diarrheal  disease  is  estab- 
lished. A  healthy  child  may  possibly  overcome 
what  a  weak  and  debilitated  one  would  not  be  able 
to.  The  number  of  bacteria,  however,  may  be 
so  great,  and  the  infection  so  intense,  that  the 
sturdiest  children  are  stricken.  Under  the  second 
condition  the  bacteria  develop  in  the  food  before 
it  is  taken  into  the  body,  and  produce  toxins. 
This  food,  taken  by  the  child,  will  produce  diarrhea 
often  with  greater  promptness  than  the  germs 
themselves  acting  within  the  body.  As  these  facts 
were  established  one  after  the  other,  it  became 
clear  that  prevention  required  effort  in  two  direc- 
tions,'first  to  maintain  the  digestive  organs  in  the 
best  possible  condition;  second,  to  prevent  the 
entrance  of  bacteria  into  the  digestive  tract.  The 
treatment  was  considerably  modified  also.  The 
bacteria  having  gained  an  entrance,  it  seemed  like 
rational  treatment  to  destroy  them  by  antiseptics. 
It  was  found,  however,  that  the  antiseptic  treat- 
ment   was   not    very    successful.     It    would    be    a 


172  •  HOW  TO    KEEP   WELL 

difficult  task  by  the  use  of  strong  antiseptics  to 
completely  sterilize  a  rubber  tube  twenty  feet  long 
containing  semi-fluid  contents.  It  is  utterly 
impossible  to  sterilize  the  intestinal  canal  by  any 
known  antiseptic.  All  the  more  active  antiseptics 
in  concentrated  strength  are  poisonous  to  the 
human  organization.  They  are,  moreover,  ab- 
sorbed before  they  can  reach  all  the  bacteria. 
There  was,  therefore,  another  demonstration  of  the 
efficacy  of  prevention  as  compared  with  cure. 

The  first  efforts  at  prevention  are  naturally 
directed  toward  destroying  bacteria  that  might  be 
contained  in  the  milk.  Hence  was  adopted  the 
system  of  sterilization  by  heat.  If  milk  be  boiled 
for  a  sufficient  length  of  time,  every  germ  and 
spore  will  be  killed,  and  if  it  is  then  protected  from 
the  air  it  can  be  kept  for  weeks.  It  was  gradually 
found,  however,  that  sterilizing  changed  the  prop- 
erties of  milk,  which  is  a  complex  and  delicate 
compound,  and  easily  injured.  It  was  found  that 
many  children  did  not  thrive  well  on  thoroughly 
sterilized  milk.  It  was  gradually  learned  that 
no  amount  of  heat  would  destroy  bacterial  poison 
already  formed  in  the  milk.  Hence  children  fed 
upon  sterilized  milk  sometimes  fell  ill  as  suddenly 
and  as  seriously  as  those  fed  upon  raw  milk.  It 
was  then   demonstrated   that  heating  to   a  point 


THE    INFECTIOUS   DISEASES         173 

considerably  below  the  boiling  temperature  was 
sufficient  to  kill  all  the  pathogenic  bacteria. 
Hence  was  developed  the  system  known  as  pasteur- 
izing, by  which  milk  is  heated  to  155°  F.  Pasteur- 
izing causes  no  alteration  in  the  taste  of  the  milk, 
and  avoids  those  chemical  changes  which  are  pro- 
duced by  higher  temperatures.  Pasteurizing  has 
almost  completely  supplanted  sterilizing  as  a 
means  of  preserving  milk.  An  apparatus  has  been 
devised  by  Freeman,  of  New  York,  by  which  a 
temperature  of  exactly  155°  can  be  obtained. 
Several  other  forms  of  apparatus  accomplish  the 
same  result  with  more  or  less  precision.  Pasteur- 
izing by  apparatus  of  this  type  is  the  most  certain 
and  least  objectionable  method  of  destroying 
bacteria  in  milk.  One  point  should  be  clearly 
understood,  for  there  is  much  miscomprehension 
regarding  it.  Pasteurizing  and  sterilizing  accom- 
plish one  result,  and  were  never  designed  to 
accomplish  more.  They  destroy  the  bacteria  in 
the  food,  and  nothing  more.  They  do  not 
render  it  more  digestible,  nor  take  away  the 
necessity  for  modifying  it. 

Pasteurizing,  while  an  improvement  over  steril- 
izing, is  still  but  a  half-way  measure  of  prevention. 
It  is  the  best  that  can  be  done  in  many  cases,  and 
must    still   be   frequently   employed,    particularly 


174  HOW   TO    KEEP   WELL 

during  warm  weather.  Rational  prevention  of  the 
summer  diseases  consists  in  attempting  to  keep 
bacteria  out  of  milk,  rather  than  allowing  them  to 
enter  and  then  destroying  them.  During  the  past 
five  years  the  whole  effort  of  those  interested  in 
this  subject  has  been  to  secure  the  production  of 
clean,  wholesome  milk.  Such  milk  must  be 
absolutely  free  from  all  disease-producing  bacteria, 
with  the  common  air  bacteria  reduced  to  a  mini- 
mum. The  results  that  have  thus  far  been  obtained 
have  been  very  remarkable,  and  are  further  con- 
sidered in  the  chapter  on  infant  feeding.  Milk 
is  by  no  means  the  only  food  which  causes  indi- 
gestion and  diarrhea.  There  is  not  a  ready- 
made  food  in  the  market  that  has  not  its  record 
of  malnutrition,  indigestion,  and  acute  diarrhea, 
were  the  full  record  known. 

The  prevention  of  the  summer  diseases  of  chil- 
dren is  thus  admirably  summed  up  by  Doctor  Holt: 
"Prevention  demands  (i)  sending  as  many  infants 
out  of  the  city  as  possible;  (2)  the  education  of 
the  laity  to  the  importance  of  regularity  in  feed- 
ing, the  dangers  of  overfeeding,  and  as  to  what  is  a 
proper  diet  for  infants  just  weaned;  (3)  proper 
legal  restrictions  regarding  the  transportation  and 
sale  of  milk;  (4)  the  exclusion  of  germs  or  their 
destruction   in   all   foods  given,   but   especially  in 


THE    INFECTIOUS   DISEASES         175 

milk,  by  pasteurizing  in  summer,  and  by  scrupulous 
cleanliness  in  bottles,  nipples,  etc.;  (5)  prompt 
attention  to  all  mild  derangements;  (6)  cutting 
down  the  amount  of  food  and  increasing  the 
amount  of  water  during  the  days  of  excessive 
summer  heat." 

The  summer  diseases  of  children  sometimes 
begin  suddenly  in  the  midst  of  perfect  health  as 
^cute  infections.  More  commonly  the  first  symp- 
toms are  mild  and  of  little  apparent  importance. 
The  prevention  of  these  disorders  in  most  cases 
may  be  summed  up  in  three  words — stop  tJie 
beginnings. 

DYSENTERY 

Under  this  term,  as  popularly  used,  are  included 
several  forms  of  disease  resembling  each  other  in 
their  more  important  manifestations.  It  is  essen- 
tially a  disease  of  tropical  regions,  but  is  common 
in  the  subtropical  countries,  and  occurs  sometimes 
during  the  summer  months  in  the  temperate 
zone.  It  is  one  of  the  great  epidemic  diseases 
of  the  world,  and  one  of  the  chief  causes  of  death 
in  tropical  regions.  Among  armies  it  causes 
more  deaths  than  result  from  battle.  There  can 
be  little  doubt  that  it  is  a  transmissible,  infectious 
disease,  although  a  specific  germ  has  not  been 
demonstrated  with  actual  certainty.      The  assur- 


176  HOW   TO   KEEP   WELL 

ance  is  growing  that  a  bacillus  discovered  by 
Flexner,  of  Baltimore,  while  investigating  tropical 
diseases  in  the  Philippines,  is  the  cause  of  epidemic 
dysentery.  In  certain  forms  of  chronic  dysentery, 
and  in  the  type  known  as  tropical  dysentery, 
the  ameba,  an  animal  parasite,  is  almost  con- 
stantly found.  It  is  the  growing  belief  that  it  is 
the  exciting  cause  of  these  forms  of  the  disease. 
The  infectious  agent  resides  within  the  intestinal 
tract,  and  must  be  eliminated  from  the  body  in  the 
dejecta. 

It  is  a  reasonable  conclusion  that  the  disease 
may  be  transmitted  by  water  or  by  food  contami- 
nated by  these  germs.  Its  dissemination  is  very 
similar  to  that  of  typhoid,  and  the  same  pre- 
cautions should  be  observed  as  have  been 
advised  for  that  disease.  By  observing  those 
precautions  dysentery  has  been  almost  eradicated 
from  the  army  stations  of  the  Philippines.  Only 
boiled  water  is  used;  the  hands  are  frequently 
washed;  infection  of  bedding,  linen,  and  towels 
is  guarded  against.  Cleanliness  in  its  strictest 
sense  is  enforced.  As  a  result,  the  report 
could  be  made  with  perfect  truth  that  it  is 
"a  record  never  surpassed  by  the  medical 
authorities  of  an  army  of  white  men  in  a  tropi- 
cal climate." 


THE    INFECTIOUS    DISEASES         177 

TETANUS 

Tetanus,  or  lockjaw,  is  an  acute,  infectious  disease 
characterized  by  spasm  of  the  voluntary  muscles. 
It  is  caused  by  the  bacillus  tctani,  discovered  by 
Nicolaier  in  1884.  It  is  a  spore-forming  germ,  and 
very  tenacious  of  life.  It  is  not  killed  by  drying, 
and  maintains  its  vitality  for  long  X->eriods.  Its 
habitat  is  the  superficial  layers  of  the  soil.  It  is 
widespread,  and  occurs  in  the  soil  of  many  locali- 
ties. This  explains  why  wounds  of  the  feet  by 
such  things  as  rusty  nails  or  splinters  are  particu- 
larly liable  to  be  followed  by  tetanus.  The  portal 
of  entrance  for  the  germs  is  a  wound  or  abrasion. 
The  first  spasm  usually  begins  about  ten  days 
after  infection,  and  rarely  later  than  fifteen  days. 

The  disease  appears  sporadically  in  many  places, 
and  sometimes  occurs  in  epidemic  form.  The  cases 
alleged  to  have  been  due  to  vaccination,  which 
occurred  in  Camden,  N.  J.,  early  in  1902,  were  the 
result  of  infection  of  the  vaccination  or  other 
wounds  which  had  not  been  protected  from  con- 
tamination. Four  deaths  from  lockjaw  occurred 
in  the  early  summer  of  1892  in  Utica,  N.  Y., 
among  children  who  had  not  been  recently  vacci- 
nated. The  toy  pistol  is  a  well-known  promoter 
of  tetanus.  The  disease  is  particularly  common 
among  grooms  and  those  who  live  and  work  about 


lyS  HOW   TO    KEEP   WELL 

stables.  Several  of  the  victims  of  the  Camden 
epidemic  were  the  children  of  such  families.  The 
Negro  race  is  particularly  susceptible  to  the  disease. 

A  form  of  tetanus  known  as  tetanus  ncoiia- 
tortmi  is  in  some  parts  of  the  world  a  very  prolific 
cause  of  death  among  young  infants.  It  usually 
begins  between  the  fifth  and  tenth  days  of  life,  and 
is  due  to  infection  of  the  unhealed  navel.  Ninety- 
five  per  cent.  die.  This  type  of  tetanus  occasion- 
ally occurs  sporadically,  but  more  commonly 
appears  in  epidemic  form.  In  one  house  in  Copen- 
hagen 1 8  cases  occurred.  In  the  little  island  of 
St.  Kilda,  of  the  Hebrides,  among  125  infants 
born,  84  died  of  tetanus.  The  facts  becoming 
known  in  Edinburgh,  some  benevolent  people  sent  a 
trained  nurse  to  the  island,  who  taught  the  mothers 
antiseptic  precautions  and  the  use  of  iodoform,  and 
the  disease  soon  disappeared.  This  form  of  tetanus 
is  particularly  common  among  the  Negroes  of  the 
South,  where  it  produces  in  some  localities  four  per 
cent,  of  the  total  mortality  from  all  causes.  In 
some  of  the  West  Indies,  half  the  mortality 
among  Negro  children  is  due  to  this  cause.  It  is 
not  of  infrequent  occurrence  in  some  parts  of 
Long  Island  and  New  Jersey. 

Tetanus  in  all  its  varieties  is  a  very  serious 
disease,  the  mortality  in  wound  cases  being  80  per 


THE    INFECTIOUS   DISEASES         179 

cent.  One  of  the  aphorisms  of  Hippocrates  was, 
"Such  persons  as  are  seized  with  tetanus  die 
within  four  days,  or  if  they  pass  these  they  recover." 
This  is  virtually  true  to-day.  The  prevention  of 
tetanus  consists  in  using  the  measures  employed 
against  all  wound  infection,  the  use  of  which  is 
protection  by  means  of  an  adequate  dressing.  In 
localities  where  it  occurs,  particular  precaution 
should  be  used  to  properly  cover  the  feet,  and  to 
immediately  cleanse  all  wounds  of  the  feet  and 
hands.  Wounds  contaminated  by  earth  or  stable 
dirt  should  receive  particular  care.  The  anti- 
toxin treatment  of  tetanus  is  considered  in  the 
chapter  on  antitoxins. 

ERYSIPELAS 

Erysipelas  is  an  acute,  contagious  disease, 
characterized  by  fever,  prostration,  and  a  peculiar 
form  of  spreading  inflammation  of  the  skin.  It  is 
caused 'by  a  special  form  of  streptococci.  Like 
all  inflammations  caused  by  those  germs,  it  is  of 
a  spreading  or  migrating  character.  In  ordinary 
cases  the  inflammation  is  limited  to  the  super- 
ficial portions  of  the  skin;  in  the  graver  cases  it 
involves  the  deeper  structures.  The  period  of 
incubation  is  from  three  to  seven  days.  It  is 
endemic  in  most  localities,  and  occasionally  becomes 
epidemic,  though  such  epidemics  are  rarely  exten- 


i«o 


HOW   TO    KEEP   WELL 


sive.     While  the   disease  is   contagious,  it   is   not 
actively    so    to    those    in    usual    health.     It    may 
be  conveyed  by  a  third  person,  and  the  germs  may 
attach  themselves  to  bedding  and  clothing.     The 
alcoholic  and  debilitated  are  particularly  suscepti- 
ble, and  a  predisposition  is  seen  in  certain  families 
and  in  certain  individuals.     Recent  surgical  cases 
and  women  in  the  puerperal  state  are  very  sus- 
ceptible to  it.     In  such  cases,  however,  it  rarely 
appears   as  erysipelas,  but   as   septic  infection,  or 
puerperal    fever.     It    is    not    received    in    general 
hospitals,  for  it  is  one  of  the  most  potent  causes  of 
blood  poisoning  and  wound  infection.     Isolation 
of  the  erysipelas  patient  should  be  strictly  carried 
out.     No  person  who  has  come  in  recent  contact 
with  such  a  case  should  enter  the  room  of  a  con- 
finement patient  or  have  anything  to  do  with  her 
care.     Neither  should  they  have  anything  to  do 
with  a  person  having  an  open  wound.     All  dressings 
and  articles  which  have  come  in  contact  with  an 
erysipelas  patient  should  be  disinfected  or  burned, 
and    the     sick-room    should     be    disinfected    and 
fumigated  before  it  is  again  occupied. 

PUS    FORMATION    AND    SEPTIC    INFECTIONS 

There  are  numerous  forms  of  suppuration  and 
wound  infection,  all  of  which  are  due  to  bacterial 
action.     The    acute    circumscribed   inflammations 


THE    INFECTIOUS    DISEASES  i8i 

which  result  in  the  formation  of  pus  are  due  in  the 
majority  of  cases  to  what  are  commonly  called 
the  pus-forming  germs.  The  most  common  of  these 
is  the  staphylococcus  pyogenes  aureus,  the  yellow 
pus-producing  staphylococcus.  While  it  does  not 
form  spores,  it  is  rather  tenacious  of  life,  and  is  not 
destroyed  as  readily  as  are  some  other  germs. 
Other  forms  of  this  bacterium  are  the  citreus,  which 
produces  a  lemon-yellow  colour,  and  the  albus, 
which  produces  white  colonies  of  germs.  These 
various  germs,  particularly  the  first  one  mentioned, 
are  the  cause  of  numerous  inflammatory  conditions, 
notably  boils,  abscesses,  felons,  inflammations  of 
the  joints,  and  sometimes  meningitis,  peritonitis, 
pleurisy,  and  other  conditions.  The  boil  is  the 
type  of  inflammation  commonly  caused  by  this 
germ.  The  inflammation  tends  to  localize  itself, 
and  does  not  spread  widely. 

There  is  another  germ  concerned  in  the  produc- 
tion of  inflammation,  namely,  the  streptococcus 
pyogenes.  This  germ  has  a  tendency  to  cause  a 
spreading  or  migratory  inflammation,  as  in 
erysipelas.  It  is  a  much  more  dangerous  germ 
than  the  first.  It  is  the  cause  of  some  of  those 
rapid  forms  of  blood  poisoning  which  result  from 
a  scratch  or  puncture.  It  gives  rise  to  the  con- 
ditions known    as    septic  infection,  or  true   blood 


i82  KOW   TO    KEEP   WELL 

poisoning.  It  is  these  families  of  germs  which 
cause  so  much  trouble  in  surgery,  and  it  is  their 
exclusion  which  has  resulted  in  so  much  improve- 
ment in  the  results  of  surgical  operations.  Pus 
contains  some  of  these  varieties  of  bacteria  in  living 
and  active  state.  When  dried  they  become  dis- 
seminated through  the  air  as  dust,  and  are  ready 
to  excite  inflammation  in  any  open  wound  or 
abrasion.  These  pus-forming  germs  are  so  widely 
disseminated  that  any  wound  exposed  to  the  air 
may  become  infected  with  them.  The  irregular 
sores  which  sometimes  follow  vaccination  are 
usually  the  result  of  infection  by  one  of  this  group 
of  germs. 

The  serious  sores  and  blood  poisonings  which 
sometimes  follow  very  minute  injuries,  such  as  the 
scratch  of  a  pin,  are  the  result  of  infection  by  one 
of  these  germs.  Hundreds  of  pin  scratches  cause 
no  trouble,  because  no  septic  bacteria  were  present. 
Finally  a  scratch  is  made  with  a  pin  which  has  been 
infected  with  some  virulent  germ,  like  strepto- 
coccus, and  dangerous  inflammation  rapidly  follows. 
Dissecting  wounds  and  post-mortem  wounds  are 
of  this  character.  The  portal  of  entrance  for  these 
septic  germs  is  usually  an  abrasion  of  the  skin  or 
mucous  membrane  or  an  open  wound.  It  does  not 
follow,  however,  that  every  wound  or  abrasion  will 


THE    INFECTIOUS   DISEASES  183 

become  septic.  Reference  was  made  in  the  chapter 
on  bacteriology  to  the  power  of  the  body  to  with- 
stand pathogenic  bacteria.  That  power  is  some- 
times particularly  marked  in  the  case  of  these 
septic  germs.  Tlie  natural  vital  energy  of  the 
tissues  of  some  individuals  seems  much  greater 
than  that  of  others.  We  frequently  see  individuals 
upon  whom  every  scratch  or  minor  injury  causes  a 
suppurating  sore.  In  others,  such  sores  are  rare, 
and  wounds  heal  readily.  The  surgeon  observes 
this  continually.  Some  of  his  patients  recover 
rapidly,  and  their  wounds  close  without  difficulty, 
while  in  others  the  healing  process  is  slow,  and 
suppuration  is  prone  to  occur  even  when  the 
greatest  precautions  are  used. 

From  these  facts  methods  of  prevention  are 
readily  adduced.  Scrupulous  cleanliness  and  the 
protection  of  wounds  and  abrasions  from  the  air 
are  the  principal  measures.  A  full  description  of 
these  methods  would  involve  a  discussion  of  the 
whole   subject   of  surgical   asepsis   and   antisepsis. 

The  most  important  of  these  are  thorough  wash- 
ing and  rewashing  of  the  hands,  with  subsequent 
disinfection,  and  the  sterilizing  of  all  instruments, 
which  is  best  attained  by  boiling  immediately 
before  they  are  used.  Both  these  measures  should 
be  employed  even  in  so  small  an  operation  as  the 


i84  HOW   TO    KEEP   WELL 

use  of  a  needle  in  opening  a  fester  or  removing  a 
sliver.  The  covering  of  wounds  by  antiseptic 
dressings  is  another  important  measure.  The 
sooner  the  dressing  is  applied  after  the  wound  is 
received,  the  better.  While  waiting  for  the 
doctor,  a  serious  wound  should  be  kept  closely- 
covered  with  cotton  or  a  clean  handkerchief  wet 
in  a  carbolic  solution.  The  effort  should  be  made 
to  keep  the  germs  out  of  the  wounds,  rather  than 
allowing  them  to  enter  and  then  attempting  to 
destroy  them  with  antiseptics.  The  character  of 
the  first  dressing,  therefore,  is  very  important.  All 
bandages  and  dressings  removed  from  suppurating 
wounds,  and  all  pus,  should  be  at  once  rolled  up  in 
paper  or  cloth  and  burned  as  soon  as  possible.  If 
this  is  not  at  once  possible,  they  should  be  thor- 
oughly soaked  in  a  strong  antiseptic  solution. 

Small  abscesses,  boils,  and  carbuncles  are  almost 
without  exception  the  result  of  local  infection. 
This  infection  may  enter  through  a  minute  abra- 
sion or  gain  admission  through  a  gland  or  at  the  root 
of  a  hair.  Boils  are  not  the  eliminating  of  so  much 
poisonous  matter  which  has  collected  in  the  body. 
That  idea  is  one  of  those  popular  fallacies  which 
has  gained  a  strong  foothold.  The  pus  is  all  pro- 
duced at  the  seat  of  the  boil  by  the  action  of 
bacteria.     Boils  are  pestiferous  visitations  which 


THE    INFECTIOUS   DISEASES         1S5 

do  no  good;  they  do  not  "clean  the  system,"  hut 
tend  to  generate  profane  language  and  an  evil 
temper.  They  sometimes  occur  in  crops,  because 
a  person  is  reduced  in  general  health  or  because 
the  tissues  have  lost  their  ability  to  withstand  the 
staphylococci.  One  boil  furnishes  abundant  seed 
material  for  others.  Great  care  should  be  exer- 
cised in  dressing  them  and  in  removing  all  the  pus 
from  the  skin.  A  carbolic  solution  should  be 
freely  used  for  a  wide  distance  around  the  boil. 
Preventing  the  recurrence  of  boils  does  not  do 
harm,  for  each  one  is  a  local  infection,  and  is  a 
drain  upon  the  system.  Small  abscesses  or  pus 
formations  of  all  kinds  should  be  treated  with  the 
same  car. 

OTHER    INFECTIOUS    DISEASES 

There  are  other  diseases  whose  infectious  char- 
acter is  either  positively  known  or  strongly  sus- 
pected. Some  of  these  are  so  rare  that  extended 
consideration  is  uncalled  for  in  this  place.  The 
origin  of  others  is  still  doubtful. 

Bronchitis  is  usually  caused  by  bacteria.  Many 
of  the  acute  "colds  in  the  chest"  present  every 
characteristic  of  an  infectious  disease.  The  onset, 
fever  and  general  malaise,  are  very  suggestive  of 
such  origin.  The  chronic  forms  of  bronchitis, 
which   accompany  gout   and  Bright 's   disease,  are 


1 86  HOW   TO    KEEP   WELL 

no  doubt  the  result  of  the  action  of  their  poisons 
upon  the  bronchial  mucous  membranes.  A 
microbic  theory  is  not  necessary  for  their  explana- 
tion. No  one  specific  germ  has  been  discovered, 
and  probably  will  not  be,  for  the  condition  may 
undoubtedly  be  caused  by  a  variety  of  germs. 
Even  if  bronchitis  be  an  infectious  disease,  exposure 
to  cold  and  wet  is  such  an  important  predisposing 
cause  that  it  must  be  considered  a  prominent  factor. 

Coryza,  or  acute  cold  in  the  head,  has  also  all  the 
characteristics  of  an  infectious  disease.  Numerous 
bacteria  have  been  found  in  the  secretions,  and 
several  varieties  undoubtedly  have  power  to  cause 
the  disease. 

Pharyngitis,  or  acute  sore  throat,  belongs  to  the 
same  group  as  do  the  preceding  diseases,  and 
probably  results  from  the  same  causes. 

Tonsillitis  is  unquestionably  a  microbic  disease. 
In  the  follicular  form  streptococci  are  most  fre- 
quently found,  while  staphylococci  are  not  uncom- 
mon. There  is  strong  evidence  to  show  that  there 
is  a  close  relationship  between  tonsillitis  and  rheu- 
matism. Much  evidence  has  been  recently  adduced 
to  show  that  the  virus  of  rheumatism  enters  the 
body  through  the  tonsils.  Certain  it  is  that  the 
tonsils  are  the  portal  of  entrance  of  several  of  the 
general  infections.     The  form  of  tonsillitis  known 


THE    INFECTIOUS    DISEASES         187 

as  quinsy  is  an  infectious  disease,  being  an  abscess 
of  the  tonsil  and  the  tissues  around  it,  caused  by 
the  pus-producing  bacteria.  There  is  a  pecuHar 
predisposition  to  the  disease  manifested  in  some 
individuals  and  in  some  families. 

Stomatitis ,  or  inflammation  of  the  mouth,  which 
appears  in  a  variety  of  forms,  is  also  in  most  cases 
a  microbic  disease.  The  form  commonly  known  as 
thrush  is  due  to  a  funguos  growth.  This  fungus 
combines  with  the  superficial  scales  of  the  mucous 
membrane  to  form  white  patches  upon  the  tongue 
and  lips.  It  produces  a  somewhat  acrid  secretion 
which  is  prone  to  disturb  the  digestion.  It  is  most 
common  in  ill-nourished  infants.  The  so-called 
canker  sores,  which  appear  in  the  mouths  of  adults, 
are  due  to  germs. 

Ephemeral  Fever  is  a  name  used  to  cover  a 
variety  of  conditions.  Certain  forms  of  mild 
fevers  are  seen  which  continue  one  or  two  days 
and  then  subside.  Such  fevers  are  sometimes  due 
to  some  disease  which  is  overlooked,  as  tonsillitis, 
grippe,  or  even  mild  pneumonia.  They  are  com- 
mon in  children,  and  are  usually  due  to  some 
intestinal  fermentation.  They  continue  for  a 
few  days,  and  upon  the  administration  of  a  laxative 
gradually  disappear.  In  New  York  a  mild  form 
of  fever  of  rather   doubtful   nature   is   sometimes 


i88  HOW   TO    KEEP   WELL 

known  as  "city  malaria."  There  is  also  a  type  of 
fever  which  runs  a  course  of  ten  days  or  more, 
sometimes  known  as  bilious  fever.  It  does  not 
present  the  characteristics  of  typhoid  fever,  nor 
the  blood  reactions  of  that  disease.  It  is  no  doubt 
due  to  some  peculiar  form  of  micro-organism  of 
not  virulent  type.  As  our  knowledge  increases, 
these  indefinite  fevers  diminish,  and  the  well- 
read  physician  sees  but  few  of  them.  It  must  be 
said,  however,  that  the  most  painstaking  examina- 
tion occasionally  fails  to  reveal  adequate  cause 
for  certain  attacks  of  fever  which  run  a  mild 
course  and  terminate  within  a  few  days  without 
serious  results. 

Dyspepsia  and  indigestion  of  certain  types, 
both  gastric  and  intestinal,  are  due  to  bacteria 
or  to  the  low  forms  of  plant  life  of  the  class  of 
yeasts  and  moulds.  Such  micro-organisms  readily 
gain  admission  to  the  stomach.  When  the  indi- 
vidual is  in  good  health,  and  the  digestive  secretions 
are  normal,  they  are  destroyed  or  fail  to  become 
active.  If  the  secretions  are  perverted,  or  if  the 
stomach  is  filled  with  improper  and  indigestible 
food,  they  gain  a  foothold  and  produce  the  various 
symptoms  of  indigestion,  of  which  fermentation 
with  gas  formation  is  the  most  common. 

Anthrax  is   an   acute  disease  due  to  the  bacillus 


THE    INFECTIOUS    DISEASES         189 

anihracis.  It  was  one  of  the  first  bacteria  dis- 
covered, having  been  observed  in  1855,  and  its 
causal  relation  to  the  disease  having  been  proved 
in  1863.  It  bore  an  important  part  in  the  early- 
history  of  bacteriology.  The  disease  affects  chiefly 
sheep  and  cattle,  but  it  is  sometimes  conveyed 
to  man  by  inoculation,  when  it  appears  as  malig- 
nant pustule.  It  may  run  its  course  as  a  localized 
carbuncle  that  heals  slowly  without  constitutional 
symptoms.  In  other  cases  the  germs  are  taken 
into  the  lungs,  and  the  disease  is  known  as  wool- 
sorters'  or  ragpickers'  disease.  When  generalized, 
it  is  serious,  but  not  always  fatal.  Prevention 
consists  in  the  killing  and  destruction  of  the  bodies 
of  all  diseased  animals.  If  buried,  they  should 
be  placed  very  deep,  for  earth  worms  may  bring 
the  bacilli  to  the  surface,  when  they  may  infect 
animals  which  eat  the  grass  or  grain  growing  there. 
Anthrax  is  the  most  widely  spread  of  all  the 
infectious  diseases,  but  is  more  common  in  Europe 
and  Asia  than  in  America.  A  protective  inocu- 
lation has  been  devised  for  use  among  animals.  It 
was  given  to  3,000,000  sheep  in  Europe,  and  seems 
to  have  largely  reduced  the  occurrence  of  the 
disease  among  them. 

Glanders  is  another    infectious    disease    of    ani- 
mals which  is  sometimes  transmitted  to  man.     It 


I90  HOW   TO    KEEP   WELL 

occurs  in  horses  or  mules,  and  is  characterized 
by  nodules  which  form  in  the  mucous  membrane 
of  the  nose.  These  ulcerate  and  produce  a  pro- 
fuse purulent  discharge  from  the  nostrils.  While 
anthrax  rarely  affects  persons  not  directly  engaged 
in  the  care  and  management  of  animals,  glanders 
may  attack  any  person  coming  near  a  diseased 
horse.  The  habit  of  a  horse  of  forcibly  blowing 
irritating  matter  from  his  nostrils  readily  scatters 
the  infectious  matter  to  wide  distances.  If 
breathed  by  a  human  being,  it  may  cause  the 
disease,  which  may  assume  the  acute  or  chronic 
type.  Acute  glanders  is  usually  fatal,  and  is  a 
most  distressing  disease.  Chronic  glanders  may 
continue  for  long  periods  without  proving  fatal. 
Nodules  of  the  same  character  as  those  found  in 
the  nostrils  sometimes  form  under  the  skin  ol 
horses,  and  the  disease  is  then  known  as  jarcy. 
These  nodules  suppurate  and  form  open  sores, 
which  are  capable  of  producing  either  glanders  or 
farcy  in  the  human  subject.  The  cause  of  glanders 
is  the  bacillus  mallei,  which  was  discovered  in 
1882.  It  is  a  well-known  germ,  and  has  been 
extensively  studied.  Glanders  is  not  strictly 
a  contagious  disease,  but  may  be  transmitted  by 
the  discharges.  The  air  about  a  glanderous 
horse  may  he  infectious,  for  it  may  contain  minute 


THE    INFECTIOUS    DISEASES  191 

particles  of  pus  disseminated  by  the  snorting  of 
the  animaL  Prevention  consists  in  the  killing  of 
all  diseased  animals.  No  horse  with  a  nasal 
discharge  should  even  be  taken  upon  the  street  or 
placed  before  any  vehicle  until  the  nature  of  the 
discharge  is  known.  Preventive  management 
of  the  human  subject  consists  in  strict  care,  and 
disposal  of  the  purulent  discharges. 

Relapsing  Fever,  commonly  known  as  famine 
fever,  or  seven-day  fever,  is  an  infectious  and  prob- 
ably a  contagious  disease,  marked  by  fever  which 
continues  for  about  a  week,  disappears  for  a  week, 
and  then  recurs.  These  relapses  sometimes  recur 
several  times.  Relapsing  fever  has  prevailed  in 
Ireland  and  other  parts  of  Europe.  It  appeared 
last  in  this  country  in  1869.  It  rarely  causes 
death  except  in  the  feeble  and  aged.  It  is  caused 
by  the  spirillum  of  Obermeier,  which  develops  in 
the  blood.  The  predisposing  causes  are  over- 
crowding and  bad  hygiene.  Its  practical  extinc- 
tion is  the  result  of  the  improved  sanitary  and 
hygienic  conditions  of  modern  times. 


CHAPTER   VI 

Antitoxins 

Antitoxin  was  the  last  link  in  the  long  chain 
of  bacteriological  discovery  the  complete  forging  of 
which  required  more  than  thirty  years.  The  earlier 
portions  of  this  work  have  been  referred  to  in 
previous  chapters.  Beginning  with  the  demon- 
stration by  Pasteur  that  putrefaction  is  the  result 
of  germ  activity,  it  was  next  proved  that  certain 
diseases  of  animals  are  due  to  the  same  cause. 
Then  followed  a  period  of  prolonged  study  in 
which  the  methods  of  isolating  germs  were 
discovered  and  their  modes  of  culture  were 
developed.  Resulting  from  this  came  the  ability 
to  study  their  life  history,  methods  of  growth, 
and  peculiarities.  Soon  after  this  followed  the 
discovery  of  a  specific  germ  in  several  infectious 
diseases  of  man.  The  fact  was  next  established 
that  it  was  not  the  germs  themselves,  but  the  poi- 
sonous products  which  they  secrete,  which  cause 
disease.     These  products  are  known  as  toxins. 

This  was  followed  by  study  of  the  obscure  and 

192  ' 


ANTITOXINS  193 

intricate  subject  of  immunity.  The  fact  had 
long  been  known  that  one  attack  of  certain  con- 
tagious diseases  usually  renders  the  patient  immune 
from  subsequent  attacks.  As  knowledge  increased, 
the  idea  that  artificial  immunity  might  be  con- 
ferred took  possession  of  many  observers.  It  was 
a  consummation  devoutly  to  be  sought,  and  most 
painstaking  research  was  devoted  to  this  end.  It 
was  then  discovered  that  certain  elements  antag- 
onistic to  the  toxin  were  developed  in  the  body, 
and  these  were  known  as  antitoxins.  It  was 
found  that  antitoxin  was  formed  after  the  intro- 
duction into  the  body  of  the  toxin  from  which 
the  germs  had  been  completely  removed  by  filtra- 
tion. This  was  an  important  step,  for  it  began  to 
be  evident  that  antitoxin  might  be  produced 
without  the  introduction  into  the  body  of  germs. 
The  germs,  once  introduced,  will  multiply,  and  it 
is  difficult  to  control  their  action.  A  chemical 
poison  can  be  regulated  as  to  dose,  and  its  action 
can  be  controlled.  It  was  then  discovered  that 
the  injection  of  a  certain  amount  of  toxin  into  an 
animal  would  result  in  the  production  of  a  certain 
definite  amount  of  antitoxin.  The  administration 
of  this  small  amount  of  toxin  would  produce  slight 
symptoms  only.  It  was  then  found  that  a  larger 
dose  could  be  injected  without  harm,  for  a  portion 


194  HOW   TO    KEEP   WELL 

would  be  neutralized  by  the  antitoxin  already 
existing  in  the  blood.  This  was  an  important 
discovery,  for  it  was  learned  that  animals  could 
receive  repeated  injections  of  toxin  of  constantly 
increasing  size,  because  the  amount  of  antitoxin 
was  steadily  increasing.  After  a  time  the  blood 
of  the  animal  would  contain  a  much  larger  amount 
of  the  antitoxin  than  it  would  even  after  an  attack 
of  the  disease.  It  was  then  surmised  that  the  blood 
of  a  large  animal  might  be  so  charged  with  anti- 
toxin that  a  portion  of  it  might  be  injected  into 
the  body  of  a  smaller  animal  and  thus  furnish 
to  it  sufficient  antitoxin  to  render  it  immune  to 
the  poison  of  the  disease  which  it  would  ordinarily 
receive  from  exposure.  This  was  proved  to  be 
the  fact,  and  the  only  remaining  step  was  to  inject 
the  serum  of  a  highly  immunized  animal  into  a 
human  subject.  This  was  done  with  success,  as 
we  all  know.  There  has  been  nothing  more 
precise  and  definite  in  scientific  discovery  than 
this  gradually  working  up  to  the  antitoxin  treat- 
ment of  diphtheria.  There  was  almost  a  mathe- 
matical demonstration  of  its  efficacy  before  the 
first  dose  had  been  given  to  a  human  subject. 

Diphtheria  has  been  the  disease  in  which  the 
most  positive  results  have  been  obtained  from 
antitoxin  treatment.     For  various  reasons  it  has 


ANTITOXINS  195 

been  most  available  for  study,  and  the  problems 
involved  have  been  easier  than  those  presented  by 
other  diseases.  The  exact  rationale  of  the  formation 
of  antitoxin  after  the  introduction  into  the  body 
of  toxin  is  still  obscure.  Opinions  still  differ, 
but  there  is  no  difference  of  opinion  regarding  the 
fact  that  it  appears  after  the  injection  of  the  toxin 
without  the  injection  of  the  germs.  The  anti- 
toxin resides  in  the  serum  of  the  blood.  It  has 
long  been  known  that  this  serum  has  properties 
antagonistic  to  germs,  and  it  is  possible  that  the 
immunity  shown  by  certain  individuals  to  certain 
diseases  is  the  result  of  some  antitoxin  element  in 
the  blood  serum. 

The  antitoxin  of  diphtheria  is  obtained  from 
the  blood  serum  of  the  horse.  This  animal  is 
selected  because  it  is  insusceptible  to  most  human 
diseases  and  can  furnish  a  large  amount  of  blood 
serum.  Absolutely  healthy  horses  are  selected. 
They  are  placed  under  strictly  hygienic  conditions 
and  are  kept  under  the  daily  inspection  of  an  expert 
veterinary  surgeon.  A  definite  quantity  of  the 
toxin  is  injected  under  the  skin.  This  is  followed 
by  slight  local  and  general  symptoms.  After  a 
few  days  another  dose,  larger  than  the  first,  is 
injected,  and  thereafter  doses  of  constantly  increas- 
ing size  are  injected  at  regular  intervals.     Anti- 


196  HOW   TO    KEEP   WELL 

toxin  gradually  forms  in  the  blood,  the  amount 
increasing  after  each  injection.  Finally,  after 
several  weeks,  the  antitoxin-forming  power  reaches 
its  limit,  which  differs  in  different  animals.  Blood 
is  then  drawn  under  the  strictest  antiseptic  pre- 
cautions; the  serum  is  separated  and  put  into 
small  vials  or  hermetically  sealed  tubes.  Enough 
is  placed  in  each  to  furnish  one  dose  of  antitoxin. 
Several  sizes  are  made,  so  that  any  dose  may  be 
obtained. 

The  method  of  measuring  the  dose  is  somewhat 
peculiar.  As  the  amount  of  antitoxin  in  each 
sample  of  serum  varies,  the  amount  of  serum  given 
would  not  furnish  a  true  guide.  The  standard 
of  measurement  is  known  as  an  antitoxin  unit. 
A  sample  of  each  batch  of  serum  is  administered 
to  a  guinea  pig,  to  which  has  also  been  given  a 
certain  dose  of  toxin.  These  animals  are  very 
evenly  susceptible  to  the  toxin,  a  certain  definite 
amount  being  necessary  to  kill  an  animal  of  given 
weight.  An  antitoxin  unit  is  the  amount  of  anti- 
toxin required  to  neutralize  one  hundred  fatal  doses 
of  diphtheria  toxin  of  standard  strength.  The 
amount  of  antitoxin  now  commonly  given  to 
protect  children  in  ordinary  cases  is  from  2,000  to 
3,000  units.  A  single  injection  in  most  cases  is 
sufficient,  but  it  may  be  necessary    to   repeat   it 


ANTITOXINS  197 

once  or  several  times.  It  is  always  given  by 
hypodermic  injection. 

When  the  use  of  antitoxin  was  begun  in  this 
country,  early  in  1895,  many  fears  were  expressed 
regarding  it,  and  it  underwent  an  ordeal  of  fierce 
criticism.  That  opposition  has  almost  com- 
pletely disappeared.  It  may  be  truthfully  said 
that  less  objection  is  made  to  its  use  than  to 
vaccination  or  to  any  other  plan  of  treatment  in 
common  vogue.  A  few  undesirable  symptoms 
sometimes  arise.  In  rare  cases  an  eruption  similar 
to  hives  occurs  in  the  second  week  after  the  injec- 
tion. This  is  annoying  rather  than  serious.  It 
seems  to  be  largely  a  personal  matter.  Among 
five  children  in  the  same  family  receiving  antitoxin 
from  the  same  bottle  at  the  same  time,  I  have 
seen  an  eruption  in  two  and  none  in  three.  Other 
undesirable  results  following  the  use  of  antitoxin, 
which  is  obtained  from  three  or  four  leading 
American  makers,  are  so  slight  and  so  rare  that  they 
need  cause  no  apprehension. 

The  importance  of  the  early  administration  of 
diphtheria  antitoxin  cannot  be  overstated.  A 
single  example  will  illustrate  this.  Among  4,120 
cases  reported  by  the  American  Pediatric  Society, 
the  death  rate  of  those  receiving  the  injection  on 
the  various  days  of  the  disease  was  as  follows : 


198  HOW   TO    KEEP   WELL 

Injection  given     ist  day  mortality         4.7  per  cent. 

2d     "  ••  7-4 

3d     "  "  8.8 

4th   "  "  20.7 

5th   "  "  35.3 


Such  figures  teach  their  own  lesson.  The  anti- 
toxin should  be  given  in  every  suspicious  case 
without  waiting  for  the  development  of  serious 
symptoms,  or  even  until  a  bacterial  culture  can  be 
examined.  The  earlier  the  dose  can  be  given  the 
more  certain  the  result  will  be.  In  a  disease  as 
serious  as  diphtheria  we  must  expect  that  there  will 
be  a  few  malignant  cases,  or  cases  occurring  in 
feeble  children  or  those  reduced  by  illness,  who 
will  succumb  in  spite  of  any  treatment.  Infants 
under  one  year,  and  particularly  under  six  months, 
have  very  little  resisting  power,  and  many  of  the 
cases  reported  above  were  at  that  age.  Some 
recent  investigations  show  that  in  183,256  cases 
of  diphtheria  occurring  in  150  cities  before  anti- 
toxin, the  mortality  was  38.4  per  cent.  Since  anti- 
toxin was  introduced,  among  132,548  cases  there 
was  a  mortality  of  14.6  per  cent.  These  cases 
were  not  all  treated,  however,  with  antitoxin. 
Among  the  cases  so  treated  the  mortality  was  9.8 
per  cent.  In  the  Boston  City  Hospital,  where  the 
treatment  has  always  been  carried  out  with  par- 
ticular knowledge  and  care,  prior  to  1895  the  mor- 


ANTITOXINS  199 

tality  was  46  per  cent.  Since  that  time,  among 
more  than  7,000  cases  treated  with  antitoxin,  the 
mortahty  has  been  12  per  cent.  It  sliould  be 
understood  that  the  death  rate  in  such  a  hospital 
is  always  high,  for  many  cases  are  moribund  and 
die  a  few  hours  after  admission,  and  there  are 
also  many  ill-nourished  children  from  the  poorest 
quarters. 

The  effect  of  antitoxin  is  sometimes  disappoint- 
ing to  parents  who  expect  a  striking  and  immediate 
result.  It  rarely,  if  ever,  produces  a  theatrical 
effect.  Improvement  is  not  commonly  seen  for 
several  hours  after  injection.  Twelve  hours  or 
more  usually  pass  before  a  change  is  apparent. 
Recovery  takes  place  by  somewhat  slow  degrees, 
one  symptom  after  another  becoming  less  urgent 
and  gradually  disappearing.  The  fever  subsides, 
appetite  returns,  the  child  seems  brighter  and 
less  prostrated,  the  membrane  gradually  disappears 
from  the  throat,  and  the  soreness  subsides.  So 
gradual  is  the  change  during  the  course  of  one  or 
two  days,' or  perhaps  longer,  that  those  who  have 
not  had  experience  with  the  unmodified  disease  in 
its  dreadful  course,  often  prolonged  through  days, 
sometimes  fail  to  appreciate  what  the  treatment 
has  accomplished. 

One  of  the  most  important  uses  of  diphtheria 


200  HOW   TO    KEEP    WELL 

antitoxin  is  for  immunizing  those  who  have  been 
exposed  to  the  disease.  For  this  purpose  a  small 
dose  is  give];!,  and  there  is  no  question  whatever 
as  to  its  efficacy  in  preventing  the  occurrence  of 
diphtheria.  If  given  soon  after  the  exposure,  in 
rare  cases  a  membrane  appears  in  the  throat,  but 
the  disease,  even  without  more  antitoxin,  is  usually 
mild.  Unfortunately,  it  does  not  confer  protection 
for  a  long  period  of  time.  An  attack  of  diphtheria 
itself  does  not  do  this,  as  does  measles  and  scarlet 
fever,  and  we  could  not  reasonably  expect  more  of 
antitoxin.  Among  i,8o8  patients  who  received 
immunizing  doses  of  antitoxin  upon  entering  the 
Children's  Hospital  of  Boston,  it  was  found  that 
the  immunity  continued  from  ten  to  twenty  days, 
and  sometimes  longer.  The  physicians  of  that 
hospital  concluded  from  their  experience  that 
certain  immunity  could  be  conferred  if  the  injec- 
tion was  given  twenty-four  hours  before  exposure, 
no  matter  how  thorough  the  exposure.  This 
period  of  immunity,  averaging  from  two  to  three 
weeks,  is  short,  but  it  is  ample  to  carry  the  child 
past  the  danger  period  after  the  exposure.  The 
period  of  incubation,  it  should  be  remembered, 
is  usually  about  two  days,  and  rarely  more 
than  six.  This  short  period  of  immunity  con- 
ferred   by     antitoxin     explains     the     reason     for 


ANTITOXINS  20I 

not  giving  it  to  every  young  child,  as  vaccination 
is  done. 

Croup. — Diphtheria  of  the  larynx,  or  mem- 
branous croup,  is  one  of  the  most  fatal  diseases  of 
childhood.  The  mortality  in  untreated  cases 
is  more  than  90  per  cent.  The  disease  involves  the 
narrowest  portion  of  the  respiratory  tract,  and 
causes  death  chiefly  by  mechanical  obstruction. 
Until  about  twenty  years  ago,  treatment  consisted 
in  tracheotomy,  in  which  an  incision  was  made 
into  the  throat  from  the  outside,  through  which  a 
tube  was  inserted.  This  reduced  the  mortality  to 
about  70  per  cent.  While  this  method  removed 
the  effects  of  obstructions,  the  child  was  still 
affected  by  a  malignant  form  of  diphtheria.  A 
great  improvement  over  tracheotomy  was  effected 
by  the  operation  of  intubation,  devised  by  Doctor 
O'Dwyer,  of  New  York.  By  this  operation  a 
small  tube  is  inserted  into  the  larynx  through 
the  mouth.  It  is  somewhat  more  effective  than 
tracheotomy  in  saving  life  in  the  cases  operated 
on.  It  has  actually  resulted  in  saving  many  more 
lives,  because  there  is  less  objection  to  its  perform- 
ance on  the  part  of  parents.  It  is,  therefore, 
done  earlier  and  in  a  greater  number  of  cases.  No 
knife  is  used,  for  there  is  no  incision  in  the  throat; 
no  anesthetic  is  required;  the  tube  can  be  quickly 


202  HOW   TO    KEEP    WELL 

and  easily  removed;  and  no  wound  is  left  behind. 
This  proved  to  be  one  of  the  most  beneficial  devices 
of  modern  medicine.  It  is  expected  to  accomplish 
one  thing,  and  one  only,  the  relief  of  obstruction  at 
the  narrowest  point  in  the  throat.  Unfortunately, 
the  diphtheritic  membrane  has  a  strong  tendency 
to  extend  downward  through  the  bronchial  tubes 
into  the  lungs.  Here  it  induces  pneumonia,  which 
is  the  cause  of  death  in  most  fatal  cases  of  croup 
after  intubation.  Various  modes  of  treatment 
were  tried  with  the  hope  of  preventing  this 
extension  and  saving  the  patients  from  the 
poisonous  effects  of  diphtheria.  Several  of 
these  methods  were  followed  by  some  benefit, 
but  the  death  rate  still  continued  between  60  and 
70  per  cent. 

Antitoxin  has  to  a  large  extent  accomplished 
these  much  desired  effects,  and  the  combination  of 
antitoxin  and  intubation  has  accomplished  one 
of  the  most  brilliant  results  of  modern  medicine. 
They  are  in  a  most  striking  way  complements 
of  each  other.  Each  alone  is  effective  in  reducing 
the  mortality  of  one  of  the  most  fatal  diseases. 
Hand  in  hand  they  have  reduced  that  mortality  to 
a  point  which  would  have  seemed  incredible  ten 
years  ago.  Antitoxin  to  a  large  degree  controls 
the    diphtheritic    process,    and    by    preventing    its 


ANTITOXINS  203 

extension  downward  into  the  lungs,  holds  it  in 
check  in  the  larynx.  Here  the  intubation  tube  can 
reach  it  and  overcome  the  mechanical  obstruction 
until  the  membrane  disappears. 

The  effect  of  antitoxin  is  more  marked  in  croup 
than  in  any  other  form  of  diphtheria.  Among  the 
best  results  reported  before  its  adoption  were  those 
of  a  certain  group  of  8,383  cases,  with  a  mortality 
of  69.5  per  cent.  The  American  Pediatric  Society, 
in  an  investigation  upon  1,704  cases  treated  b}^ 
antitoxin,  found  a  mortality  of  21.12  per  cent. 
The  most  remarkable  feature,  however,  shown  by 
these  cases,  was  the  large  number  which  did  not 
require  operation.  The  investigation  proved  that, 
with  antitoxin,  six  cases  of  croup  in  ten  did  not 
require  an  operation,  and  eight  in  ten  recovered. 
Doctor  O'Dwyer's  own  experience  was  very  strik- 
ing. Before  his  lamented  death  he  was  the  great- 
est authority  upon  this  class  of  disease.  He  had 
performed  470  operations  with  a  death  rate  ranging 
from  70  to  73  in  each  hundred,  the  average  being 
72.44.  And  then  something  happened  which 
stopped  forever  these  terrible  rates  of  mortality, 
and  that  something  was  antitoxin.  After  its 
introduction.  Doctor  O'Dwyer  did  59  operations 
with  a  mortality  of  23.7  per  cent.  This  means 
that   the   lives   of   229   children   would   have   been 


204  HOW   TO    KEEP   WELL 

saved   in   the  practice  of  this  one  man  had  anti- 
toxin come  ten  years  earlier. 

The  rule  should  be  in  croup,  as  in  other  forms  of 
diphtheria,  to  administer  the  antitoxin  at  the 
first  definite  symptom,  and  not  waste  time  and 
the  strength  of  the  patient  with  depressing  and 
futile  treatment,  which  can  accomplish  little  or 
no  good.  These  investigations  of  the  American 
Pediatric  Society  were  completed  more  than  four 
years  ago.  Since  that  time  antitoxin  has  been 
given  more  freely  and  more  promptly,  and  recent 
results  have  been  even  better  than  those  reported. 
"Few  of  the  most  useful  methods  of  treatment 
have  been  subjected  to  the  same  fierce  criticism 
as  was  the  antitoxin  of  diphtheria,  and  still  fewer 
have  borne  the  ordeal  as  triumphantly,"  says  the 
British  Medical  Journal. 

other'  antitoxins 

Numerous  other  antitoxins  have  been  produced, 
but  no  results  have  been  obtained  as  satisfactory 
as  those  resulting  from  the  use  of  diphtheria  anti- 
toxin. A  reference  to  the  table  showing  the 
results  of  diphtheria  antitoxin  when  given  early 
will  afford  one  explanation  for  the  failure  to  obtain 
good  results  with  other  serums.  It  will  be  seen 
by  the  table  that  effective  results  are  obtained 
only  when  the  antitoxin  is  given  early.      In  diph- 


ANTITOXINS  205 

theria,  we  have  conditions  differing  from  those 
found  in  almost  any  other  disease.  The  germs 
do  not  enter  the  body,  but  develop  in  the  diph- 
theritic membrane,  where  they  elaborate  their 
poison,  which  is  then  absorbed  into  the  circula- 
tion. The  membrane  in  the  first  day  or  two,  there- 
fore, is  a  danger  signal  which  gives  warning  of  the 
illness  which  is  to  follow,  when  the  germs  have 
multiplied  and  developed  their  poison.  In  other 
diseases,  as  pneumonia,  we  have  no  means  of 
knowing  that  the  germs  are  present  until  the  patient 
is  suddenly  taken  ill  and  the  disease  is  under  full 
headway.  Administering  an  antitoxin  then  is  like 
administering  it  in  diphtheria  on  the  fourth  or 
fifth  day.  While  some  benefit  is  secured,  and 
the  death  rate  somewhat  diminished,  the  marked 
results  of  early  administration  are  not  obtained. 
This  is  one  reason  why  we  cannot  expect  the  same 
results  in  other  diseases  that  we  obtain  in  diph- 
theria. The  tetanus  antitoxin  is  a  clear  example 
of  this  difficulty.  A  high  degree  of  immunity 
against  tetanus  can  be  conferred  on  animals,  which 
then  yield  a  very  potent  serum.  When  the  disease 
is  under  headway  in  animals,  however,  this  same 
serum  is  ineffective  to  cure.  This  is  due  to  the 
damage    which    the    toxin    has    already   produced 


2o6  HOW   TO    KEEP    WELL 

upon  the  nerve  cells  by  the  time  the  symptoms 
have  appeared. 

In  several  diseases  attempts  to  produce  an 
antitoxin  have  so  far  failed.  Those  diseases 
caused  by  strictly  parasitic  germs  offer  peculiar 
difficulties,  for  it  is  impossible  to  cultivate  them 
outside  the  body  with  sufficient  vigour  to  produce 
an  active  toxin.  This  renders  it  impossible  to 
secure  sufficient  toxin  to  use  upon  animals  to 
produce  an  antitoxin.  A  very  serious  obstacle 
in  other  diseases  is  the  fact  that  no  soluble  toxin 
can  be  obtained  with  which  to  generate  the  anti- 
toxin. The  serum  for  one  disease  has  no  effect 
upon  other  diseases.  Even  the  diphtheria  serum, 
effective  as  it  is  against  the  toxins  produced  by 
the  diphtheria  bacilli,  has  little  effect  in  neutralizing 
the  toxins  produced  by  the'  pseudo-diphtheria 
germs.  It  is  clearly  demonstrated  that  each  germ 
must  have  an  antitoxin  of  its  own. 

Antistreptococcic  Serum. — This  serum  has  been 
employed  for  several  years  in  the  treatment  of 
septic  infections.  It  has  been  fairly  successful 
in  lirriited  cases,  but  the  dose  is  large  and  not 
entirely  free  from  deleterious  effects.  It  cannot 
be  called  a  marked  success.  It  has  been  used 
chiefly  in  scarlet  fever,  erysipelas,  and  certain 
forms  of  pus  infection.     A  special  form  of  serum 


ANTITOXINS  207 

for  use  in  scarlet  fever  has  very  recently  been  ob- 
tained by  Moser,  of  Vienna,  which  promises  to 
give  better  results  than  any  yet  used  in  that  disease. 

Pneumonia  Antitoxin. — This  serum  has  quite 
satisfactorily  fulfilled  the  requirements  of  labora- 
tory administration.  It  will  preserve  animals 
from  many  times  a  fatal  dose  of  the  virulent  culture 
of  the  pneumonia  germ.  The  actual  application 
in  cases  of  pneumonia  has  failed  to  show  that  it  is 
of  much  utility,  from  causes,  perhaps,  already 
suggested.  A  difficult}^  of  producing  this  serum 
had  been  the  fact  that  the  pneumonia  germ  does 
not  produce  in  an  artificial  culture  any  strong 
soluble  toxin. 

Typhoid  Antitoxin. — More  than  one  form  of 
serum  has  been  produced  as  a  typhoid  antitoxin. 
One  of  these  was  used  as  a  preventive  agent  quite 
extensively  at  Lady  smith  during  the  South  African 
war.  The  results  were  apparently  quite  satis- 
factory, but  not  brilliant.  It  has  also  been  used 
with  apparently  moderate  results  in  India  as  a 
preventive  measure. 

Plague  Antitoxin  and  Serujn. — The  preventive 
plague  vaccine  of  Haffkine  continues  to  be 
employed  with  increasing  confidence  as  a  protective 
agent  against  bubonic  plague.  As  the  immunity 
it  conveys  is  short,  it  is  necessary  that  it  be  repeated 


2o8  HOW   TO    KEEP   WELL 

about  once  in  twenty  days.  The  curative  serum 
of  Yersin,  differing  from  the  vaccine,  has  reduced 
the  deatli  rate  somewhat. 

Hydrophobia  Inoadation. — Statistics  prove  the 
importance  of  the  Pasteur  treatment  of  hydro- 
phobia as  a  preventive  measure  in  man.  Horsley, 
of  England,  after  extensive  investigation,  found 
that  15  per  cent,  of  those  bitten  by  rabid  dogs 
contracted  the  disease,  and  40  per  cent,  of  those 
bitten  by  wolves.  The  mortality  of  those  affected 
ranges  from  60  to  80  per  cent.  At  the  lowest  rate 
of  mortality,  we  should  expect  9  per  cent,  of  deaths 
of  those  bitten  by  dogs.  The  cases  treated  in 
Paris  for  eight  years  numbered  13,817,  and  the 
mortality  was  but  .5  per  cent.  Allowing  for  all 
possible  errors,  this  certainly  seems  to  show 
undoubted  effects  of  the  treatment.  Preventive 
inoculation  can  be  performed  successfully  in  dogs 
who  have  been  injected  in  the  laboratory  with 
active  virus.  It  is  not,  therefore,  unreasonable 
to  suppose  that  the  same  inoculation  will  be  effective 
in  man  if  given  early.  This  subject  is  further 
considered  in  the  section  on  hydrophobia. 

Tetanus  Antitoxin. — The  poison  of  tetanus  is  a 
tox-albumin  of  extraordinary  power.  It  is  prob- 
ably the  most  virulent  poison  known.  An  immu- 
nizing serum  has  been  obtained  of  decided  power  as 


ANTITOXINS  209 

shown  by  the  fact  that  it  will  neutralize  the  effect 
of  large  doses  of  the  toxin  if  given  to  animals,  pro- 
vided it  be  administered  before  the  toxin  has  had 
opportunity  to  injure  the  nerve  centres.  If  such 
injury  has  taken  place,  it  is  not  to  be  expected 
that  the  cells  can  be  restored.  AVe  see  in  tetanus 
and  pneumonia  two  of  the  difficulties  in  producing 
practically  effective  antitoxins.  In  the  one  case 
an  effective  antitoxin  has  been  produced,  but  no 
indication  usually  arises  for  its  administration  until 
the  poison  of  the  disease  has  caused  irreparable 
physical  injury.  In  the  second  class,  owing  to 
peculiarities  in  the  growth  of  the  germ,  an  ade- 
quate antidote  has  not  been  obtained. 

Tuberculosis  Antitoxin. — Several  antitoxins  for 
tuberculosis  have  been  obtained  by  different 
workers,  and  have  all  received  the  most  careful 
attention.  Most  of  them  have  been  tested  with 
particular  care  at  Saranac.  While  one  or  two 
have  shown  some  slight  degree  of  power,  they 
have  not  developed  any  marked  curative  influence 
over  the  course  of  the  disease.  At  the  present 
writing  there  is  no  antitoxin  for  tuberculosis 
worthy  of  reliance.  Behring,  whose  name  is  so 
intimately  associated  with  diphtheria  antitoxin, 
has  recently  expressed  the  belief  that  a  serum  for 
the  treatment  of  tuberculosis  was  nearing  perfection. 


CHAPTER   VII 

Vaccination 

Vaccination  is  the  most  potent  measure  of 
prevention  which  man  has  yet  discovered  in  his 
long  warfare  with  disease.  That  doubt  as  to  its 
efficiency  exists  to-day  is  due  largely  to  ignorance 
of  facts.  There  is  a  peculiar  tendency  in  certain 
minds  to  question  even  the  simplest  propositions. 
It  must  be  said  that  this  country  seems  to  afford 
extraordinary  facilities  for  the  development  of 
that  particular  form  of  mental  pervert  which 
perpetually  takes  the  opposite  side  and  objects  to 
the  established  order  of  things.  It  is  to  this  class 
that  those  belong  who  may  be  called  professional 
anti-vaccinationists.  There  are,  however,  people 
in  every  community  who,  through  lack  of  knowl- 
edge, believe  themselves  to  be  opposed  to  vacci- 
nation. They  are  intelligent  and  conscientious, 
and  form  a  class  apart  from  the  professional  agi- 
tators, to  whom  reference  has  just  been  made. 
Almost  without  exception  the  articles  which  appear 
against   vaccination   are   written   by   members   of 

2IO 


VACCINATION  211 

the  first-mentioned  class.  They  are  mostly  written 
in  a  petulant  tone,  and  are  utterly  lacking  in  logic. 
They  are  extreme  in  statement,  and,  as  a  rule, 
are  positively  untruthful.  The  extreme  views 
held  by  the  professional  anti-vaccination  agitators 
are  shown  by  the  following  statement  of  principles 
taken  from  an  editorial  article  in  the  September, 
1902,  issue  of  the  organ  of  the  American  Anti- 
vaccination  Society:  "I  advocate:  no  vaccination, 
no  medical  laws,  no  medical  health  boards." 

The  number  of  those  who  conscientiously  oppose 
vaccination  is  very  small.  The  head  of  the  New 
York  Health  Department,  although  a  strong 
believer  in  vaccination,  last  winter  opposed  a 
compulsory  vaccination  bill  pending  before  the 
Legislature.  His  ground  was,  that  it  would  arouse 
opposition  and  was  unnecessary,  as  the  inspectors 
of  the  departm^ent  found  virtually  no  one  who 
refused  to  be  vaccinated. 

It  is  entirely  reasonable  to  insist  that  in  a  pro- 
cedure like  vaccination  certain  requirements  should 
be  fulfilled.  A  vaccination  sore  should  pass 
through  certain  well-defined  stages.  If  it  does  not 
do  so,  it  is  not  an  adequate  vaccination,  and  can- 
not be  expected  to  confer  full  protection.  The 
following  is  the  typical  course  of  a  vaccination.  On 
the  third  or  fourth  day  after  vaccination,  a  faint 


212  HOW   TO    KEEP    WELL 

redness  appears  at  the  point  of  inoculation.  This 
redness  gradually  increases,  and  a  little  reddish 
papule  is  formed.  The  papule  gradually  changes 
to  a  vesicle,  which  at  first  contains  a  thin,  trans- 
parent fluid.  By  the  eighth  day  the  fluid  has 
become  yellowish  in  colour,  and  in  the  centre  a 
little  depression  may  be  seen.  About  this  time 
a  circle  of  inflammation  appears  about  the  vesicle, 
which  is  called  the  areola.  By  the  tenth  day  the 
inflamed  skin  is  tense  and  painful,  and  streaks  of 
redness  often  extend  out  for  a  considerable  distance. 
By  the  twelfth  day  the  vesicle  begins  to  dry,  and  by 
the  fifteenth  day  a  crust  has  formed.  This  crust 
is  of  mahogany  colour,  rough,  but  thinner  in  the 
centre  than  toward  the  edges.  It  rarely  falls  before 
the  end  of  the  third  week.  The  scar  is  at  first 
red,  but  soon  fades,  and  has  a  pitted  or  streaked 
appearance. 

About  the  tenth  day,  and  often  earlier,  general 
symptoms  frequently  appear.  There  may  be 
a  slight  fever  with  chilly  sensations  and  malaise, 
but  these  symptoms  are  rarely  severe  or  prolonged. 
By  recent  methods  of  vaccination  the  general 
symptoms  are  often  very  mild  and  the  local  sore  is 
small.  If  it  pursues  the  course  described,  even  if 
the  soreness  is  slight,  it  is  adequate.  On  the 
other  hand,  severe  soreness  is  not  itself  an  evidence 


VACCINATION  213 

of  satisfactory  vaccination.  If  there  is  a  radical 
departure,  particularly  in  the  earlier  stages,  from 
the  course  outlined,  the  vaccination  is  not  to  be 
relied  on. 

As  to  the  dangers  of  vaccination,  they  are  few. 
When  the  operation  is  properly  done  with  properly 
selected  lymph,  and  the  sore  is  adequately  protected, 
the  dangers  are  virtually  none.  The  serious  results 
which  sometimes  follow  vaccination  usually  come 
from  infection  of  the  sore.  The  lymph,  which  is 
prepared  to-day  by  certain  well-known  and  repu- 
table makers,  does  not  contain  pathogenic  bacteria. 
The  charges  made  against  vaccination,  when 
investigated,  are  almost  invariably  found  to  be 
without  foundation.  The  physician  often  hears 
of  the  appearance  of  a  disease  attributed  to  vacci- 
nation performed  weeks,  months,  or  even  years 
before.  Illness  is  so  common  among  young  chil- 
dren that  coincidence  is  not  an  uncommon  factor. 
Many  inherited  weaknesses  are  attributed  to 
vaccination  which  could  by  no  possibility  result 
from  such  a  cause.  It  is  comforting  to  the  parents 
to  have  some  such  explanation  for  defects,  rather 
than  to  attribute  them  to  inheritance  or  improper 
management,  and  vaccination  is  the  catch-all  for 
such  purposes.  A  case  of  bowlegs,  the  result 
of  rickets  caused  by  feeding  with  condensed  milk, 


214  HOW   TO    KEEP   WELL 

was  recently  attributed  in  my  hearing  to  vaccina- 
tion, and  nothing  would  shake  the  faith  of  the 
mother  in  her  theory.  The  bowlegs  did  not 
appear  until  after  the  vaccination;  and  it  had 
been  done  on  the  leg. 

Most  of  the  arguments  made  to-day  against 
vaccination  date  back  to  the  time  of  Birch  and 
Rogers,  in  1805,  and  are  based  in  considerable 
measure  upon  experience  at  a  time  when  arm-to- 
arm  vaccination  was  practised.  By  that  method 
blood  diseases  were  undoubtedly  occasionally 
transmitted.  The  bovine  species,  from  which 
all  vaccine  lymph  is  now  obtained,  is  not  suscepti- 
ble to  syphilis,  and  that  disease  is  never  transmitted 
by  vaccination.  It  is  a  peculiar  disease  in  its 
manifestations.  Infants  affected  with  it  are  very 
frequently  born  apparently  healthy,  and  the  first 
signs  usually  show  themselves  during  the  third 
and  fourth  weeks.  Many  cautious  physicians, 
therefore,  refuse  to  vaccinate  a  child  before  the 
end  of  the  sixth  week.  The  disease  has  many 
times  been  charged  to  vaccination,  and  physicians 
have  received  undeserved  censure,  when  it  was  in 
fact  congenital. 

Tuberculosis  is  not  transmissible  by  modern 
vaccine  lymph.  It  is  extremely  doubtful  whether 
tubercle  bacilli  ever  appear  in  the  lymph  even  in 


VACCINATION  215 

animals  suffering  from  the  disease.  To  guard 
against  any  such  chance,  however,  the  leading 
makers  examine  post-mortem  every  calf  from 
which  lymph  has  been  taken.  If  any  evidence  is 
fomid  of  tuberculosis  or  other  disease,  the  lymph 
from  that  animal  is  rejected.  Moreover,  bac- 
terial examinations  are  made  of  all  samples  of 
lymph.  A  few  great  firms  make  much  of  the 
lymph  now  used  in  this  country,  and  could  not 
afford  to  have  accidents  happen  from  the  use  of 
their  products. 

Serious  sores  are  caused  by  extraneous  germs. 
Their  introduction  may  result  from  lack  of  care  in 
performing  the  operation,  but  more  often  from 
improper  care  or  injury  after  it  is  performed. 
Vaccination  should  be  done  with  surgical  cleanli- 
ness. The  sore  may  become  infected  like  any 
other  abrasion  of  the  skin,  and  requires  adequate 
care.  In  this  way  purulent  infection  and  erysipelas 
may  occur.  Infection  is  more  common  when 
vaccination  is  done  on  the  leg,  where  it  is  more 
apt  to  be  infected  with  dust.  Little  girls  who 
are  vaccinated  on  the  leg,  and  are  then  allowed  to 
run  about  with  the  sore  unprotected,  are  par- 
ticularly liable  to  develop  complications.  Such 
complications  may  be  prevented  by  a  protective 
dressing.     A  heavy  surgical  dressing  is  not  ad  vis- 


2i6  HOW   TO    KEEP   WELL 

able,  as  it  sweats  and  softens  the  scab.  Shields 
are  more  apt  to  cause  trouble  than  to  prevent  it. 
This  is  particularly  true  of  those  that  are  covered 
or  have  hard  edges.  Talcum  powder  should  be 
freely  used,  particularly  if  the  sore  be  moist.  -A 
light  gauze  bandage,  changed  frequently,  is  the 
best  dressing  when  it  does  not  stick  in  the  sore. 
When  there  is  considerable  soreness,  or  the  dressing 
sticks,  a  light  wire  shield  or  a  perforated  felt  shield 
of  large  size  is  admissible,  and  often  gives  much 
comfort.  A  few  turns  of  light  gauze  bandage 
should  be  placed  over  this.  Tearing  off  the  scab, 
or  any  other  serious  injury  to  the  sore,  should  be 
reported  at  once  to  the  physician.  Should  the 
sore  have  become  infected  and  purulent,  he  should 
also  be  consulted. 

The  very  effectiveness  of  vaccination  has 
rendered  people  ignorant  of  its  value.  So  little 
smallpox  is  seen  at  the  present  day  that  they  have 
become  apathetic  regarding  it,  and  in  many  locali- 
ties vaccination  is  much  less  thoroughly  carried 
out  than  it  was  a  hundred  years  ago.  With  a 
full  knowledge  of  the  seriousness  of  the  disease, 
and  with  the  clear  evidence  of  the  efficacy  of  vacci- 
nation, the  operation  was  then  extensively  and 
thoroughly  performed,  and  the  disease  in  many 
localities  was  completely  extirpated.     In  Denmark, 


VACCINATION  217 

for  example,  the  practice  was  so  effectively  enforced 
that  in  1826  there  had  not  been  a  case  of  small- 
pox for  eleven  years.  It  was  then  reintroduced 
by  a  traveler  from  Hamburg.  In  Sweden  the 
mortality  dropped  from  an  average  of  2,045  deaths 
in  a  year  to  480.  In  Vienna,  in  1800,  the  deaths 
from  smallpox  had  averaged  835  a  year.  After 
the  enthusiastic  introduction  of  vaccination  in 
1 80 1,  the  deaths  fell  during  the  four  following 
years  to  164,  61,  27,  and  2  respectively. 

As  to  what  may  be  expected  from  vaccination, 
we  may  quote  the  words  of  Jenner,  whose  claims, 
though  always  positive,  were  judicious^  and  by 
no  means  extravagant.  His  own  words  were: 
"Duly  and  efficiently  performed,  it  will  protect 
the  constitution  from  subsequent  attacks  of  small- 
pox as  much  as  that  disease  itself  will.  I  never 
expected  that  it  would  do  more,  and  it  will  not, 
I  believe,  do  less."  Shortly  before  his  death  he 
said,  "My  opinion  of  vaccination  is  precisely 
what  it  was  when  I  first  promulgated  the  dis- 
covery." 

It  will  thus  be  seen  that  no  exaggerated  claims 
were  made  by  Jenner,  nor  have  there  been  by  any 
judicious  physician.  Vaccination  is  not  expected 
to  protect  from  smallpox  more  than  will  the 
disease  itself.     The  infectious  diseases  are  occasion- 


2i8  HOW   TO    KEEP   WELL 

ally  repeated  in  the  same  individual.  Second 
attacks  of  smallpox  are  very  uncommon.  Marson 
saw  forty-seven  second  attacks  among  5,982 
smallpox  patients.  Haeser  states  that  in  Verona 
twenty-four  cases  of  second  attack  were  observed 
witliin  ten  A^ears.  This  means  that  the  period  of 
immunity  is  not  always  lifelong.  A  limited  period 
of  immunity  is  common  to  several  of  the  infectious 
diseases.  In  diphtheria,  for  instance,  immunity 
continues  for  but  a  few  weeks.  In  smallpox, 
while  in  some  cases  it  is  lifelong,  in  others  it  is 
limited.  It  is  to  be  expected,  therefore,  that  the 
immunity  conferred  by  vaccination  may  have  its 
limits,  and  it  is  not  a  valid  argument  against  the 
procedure  that  it  must  be  performed  more  than 
once. 

Jenner  studied  the  subject  with  which  his  name 
is  so  intimately  associated  with  the  minutest  care, 
and  was  a  master  of  it  in  all  its  details.  Upon 
one  essential  point  only  was  he  in  error.  He 
believed  that  vaccination,  thoroughly  and  properly 
performed,  would  insure  immunity  for  life.  This 
was  not  unnatural,  for  he  saw  absolute  immunity 
conferred  by  the  operation,  and  it  required  man}^ 
years  of  observation  to  demonstrate  that  such 
immunity  might  not  be  perpetuated  during  the 
life  of  the  individual. 


VACCINATION  219 

The  first  attempt  to  check  the  ravages  of  small- 
pox was  by  inoculation.  The  idea  was  derived 
from  the  Levant,  where  the  system  has  long  been 
practised.  It  consisted  in  inoculating  the  system 
with  virus  from  a  smallpox  patient.  It  is  the 
fact  that  the  disease  produced  by  such  inoculation 
is  usually  less  serious  than  that  acquired  by  ordi- 
nary exposure,  and  the  death  rate  is  much  lower. 
Still  it  is  considerable.  It  seems  strange  at  first 
thought,  therefore,  that  the  operation  did  not 
result  in  good.  The  patient  was  as  dangerous  to 
others  as  was  the  one  with  the  regular  disease,  and, 
hence,  each  case  formed  a  new  focus  of  infection. 
Many  cases  ran  such  a  mild  course  that  the  patients 
could  not  be  properly  restrained,  and  proved 
a  public  danger.  As  a  result  of  these  causes, 
therefore,  the  system  of  inoculation  did  not  dimin- 
ish the  frequency  of  the  disease  in  England.  It 
must  be  said,  however,  that  the  attempt  to  limit 
it  by  this  means  was  entirely  proper  and  legitimate. 

The  first  vaccination  of  a  human  subject  was 
performed  by  Edward  Jenner  on  May  14,  1796. 
He  had  long  been  studying  the  question,  which 
had  been  called  to  his  attention  by  the  fact  that 
the  milkmaids  of  certain  districts  of  England 
rarely  contracted  smallpox.  It  was  a  matter  of 
popular,  though  local,  observation  that  the  immune 


220  HOW   TO    KEEP    WELL 

persons  who  had  not  had  smallpox  had  been  inocu- 
lated by  cowpox.     Little  James   Phipps  was  the 
first  subject.      His  vaccination  ran  a  typical  course, 
and  six  weeks  after  a  second  vaccination,  as  Jenner 
had     confidently     predicted,    produced     not     the 
slightest    effect.     After   other   unsuccessful   trials, 
the   boy   was   taken   through   a  smallpox   hospital 
without  the  slightest  harm,  as  we  of  the  present 
day  can  readily  believe.     Two  years  later  Jenner 
published    his    observations    in    a    little    book    of 
seventy -five  pages  entitled,   "An  Inquiry  into  the 
Cause  and  Effects  of  the  Variolae  Vaccinae,  a  Disease 
Discovered  in   Some  of  the  Western   Counties  of 
England,  Particularly  Gloucestershire,  and  Known 
by  the    Name   of    Cowpox."     The   importance   of 
this  little  volume  and  its  epoch-making  character 
is  proof  that  the  reputation  of  an  author  or  scientist 
rests  not  upon  how  much  but  how  good  his  work  is. 
From    the    publication    of    this    little    book    the 
adoption   of   vaccination   was   very   rapid,    and   it 
soon  spread  over  the  civilized  world.      Its  enemies 
were,    to    be    sure,    many    and    venomous.     The 
system    was    opposed    by    many    physicians,    and 
was    denounced    from    many    pulpits    with    great 
bitterness   as   an   attempt  to  beastialize  the  race. 
It,  however,  made  headway  in  vSpite  of  all  opposi- 
tion.    The  first  vaccination  in  America  was  per- 


VACCINATION  221 

formed  in  Boston,  on  July  8,  1800,  by  Doctor 
Benjamin  Waterhouse,  Professor  of  Practice  of 
Physic  at  Harvard.  He  vaccinated  seven  of  his 
own  children,  six  of  the  vaccinations  being  suc- 
cessful. Shortly  afterward  three  of  them  were 
sent  to  the  smallpox  hospital  and  one  was  inocu- 
lated with  smallpox.  None  of  these,  it  is  needless 
to  say,  contracted  the  disease.  The  first  vacci- 
nation in  New  York  was  performed  by  Doctor 
Seaman,  in  May,  1801.  The  operation  was  intro- 
duced into  the  southern  States  through  the  personal 
efforts  of  Thomas  Jefferson,  then  President,  who 
fully  understood  the  ravages  of  the  disease  among 
the  coloured  population. 

Jenner  vaccinated  all  who  came  to  him.  There 
were  sometimes  300  waiting  at  his  door.  He  would 
have  become  impoverished  were  it  not  for  liberal 
grants  from  Parliament.  He  sent  out  lymph  to 
the  ends  of  the  world,  and  carried  on  a  wide 
correspondence.  He  became,  in  his  own  words, 
"Vaccine  Clerk  to  the  World."  He  died  on  Janu- 
ary 26,  1823,  and  was  buried  in  the  village  church, 
an  offer  of  a  grave  in  Westminster  having  been 
declined  by  his  family.  He  was  modest,  and 
fond  of  a  quiet  life  and  simple  pleasures;  a  man 
of  great  practical  sagacity  as  well  as  originality 
of  mind.     The  faith  in  vaccination,  and  the  honour 


222  HOW   TO    KEEP    WELL 

in  which  Jenner  was  held  by  his  own  generation, 
who  understood  smaUpox  so  well,  is  shown  by  the 
fact  that  Parliament  twice  voted  him  grants  of 
money  amounting  to  ;^3 0,000,  while  Napoleon, 
the  bitter  foe  of  the  English,  liberated  prisoners 
at  his  request. 

To  comprehend  what  vaccination  has  done  for 
the  world,  we  must  understand  what  smallpox  was 
when  Jenner  first  announced  his  great  discovery. 
Its  extreme  contagiousness,  its  excessive  rate  of 
mortality,  its  loathsome  character,  and  the  maim- 
ing and  disfigurement  it  left  behind,  combined  to 
make  it  the  most  serious  scourge  from  which  the 
race  has  suffered.  It  has  been  justly  described 
as  the  "Attila  of  diseases,  the  very  scourge  of  God, 
overrunning  countries  and  destroying  whole  popu- 
lations." When  Jenner  performed  his  first  vacci- 
nation, in  1796,  smallpox  was  causing  one-tenth 
of  all  the  deaths  of  the  human  race.  Bernouilli, 
the  mathematician,  estimated  that  more  than 
60,000,000  of  the  inhabitants  of  Europe  died  from 
smallpox  during  the  eighteenth  century,  being  an 
average  of  600,000  a  3^ear.  Others  place  the  number 
even  higher.  Specific  proof  of  its  fatality  is  shown 
by  Cowan's  vital  statistics  of  Glasgow.  He  states 
that  between  1783  and  1792,  36  per  cent,  of  all  the 
deatlis  under  ten  years  were  due  to  smallpox,  and 


VACCINATION  223 

between  1793  and  1802,  32  per  cent,  were  due  to 
that  cause.  These  are  no  uncommon  figures,  for 
it  was  asserted  by  others  that  one-third  of  all 
deaths  under  ten  years  were  due  to  smallpox.  It 
was  estimated  by  Condamine  that  this  foul 
disease  destroyed  or  disfigured  the  fourth  part 
of  mankind. 

When  smallpox  was  introduced  into  Mexico  by 
the  Spaniards  in  1520,  3,500,000  died  within 
a  few  years.  In  1737,  70  per  cent,  of  the  people 
of  Greenland  died  of  smallpox.  In  1707,  in  Ice- 
land, 18,000  in  a  population  of  50,000  died  in  a 
single  year.  It  is  believed  that  6,000,000  North 
American  Indians  fell  victims  to  its  ravages.  It 
has  done  more  to  exterminate  the  aborigines  of 
this  continent  than  any  other  cause.  In  1838 
the  destruction  of  life  was  enormous,  whole  tribes 
being  exterminated.  Among  half-civilized  nations 
the  appearance  of  smallpox  often  caused  the  aban- 
donment of  whole  towns,  the  sick  being  left  to  their 
fate.  The  capital  of  Tibet,  for  example,  was  at 
one  time  left  without  inhabitants  for  several  years 
after  a  visitation  of  the  disease.  In  the  present 
century  Ceara,  in  Brazil,  was  visited  b}^  smallpox, 
and  in  a  population  of  70,000  there  were  40,000 
victims. 

Among     civilized     nations     the     ravages     were 


224  HOW   TO    KEEP   WELL 

almost  equally  great.  It  attacked  every  class 
and  order  from  the  peasant  to  the  king.  It  wrought 
wholesale  havoc  among  royal  families,  notably 
those  of  England  and  Austria.  When  Louis  XV. 
of  France  died  of  smallpox,  the  corpse  was  deserted 
by  every  one  except  a  few  priests,  who  were 
detailed  and  forced  to  perform  the  last  rites. 
The  disease  had  a  marked  influence  not  only 
upon  the  history  of  nations,  but  in  modifying  the 
character  and  habits  of  life  of  the  people. 

Macaulay  refers  frequently  to  smallpox  in  his 
history  of  England,  and  in  the  fifth  volume  thus 
speaks  of  it:  "That  disease  over  which  science 
has  achieved  a  succession  of  glorious  and  benefi- 
cent victories  was  then  (in  the  last  years  of  the 
seventeenth  century)  the  most  terrible  of  all  the 
ministers  of  death.  The  havoc  of  the  plague  has 
been  more  rapid,  but  the  plague  had  visited  our 
shores  only  once  or  twice  within  living  memory. 
The  smallpox  was  always  present,  filling  the 
churchyard  with  corpses,  tormenting  with 
constant  fears  all  those  whom  it  had  not  yet 
stricken,  leaving  on  those  whose  lives  it  spared 
the  hideous  traces  of  its  power,  turning  the  babe 
into  a  changeling  at  which  the  mother  shuddered, 
and  making  the  eyes  and  cheeks  of  the  betrothed 
maiden  objects  of  horror  to  her  lover." 


VACCINATION  225 

"If  a  modern  traveler,"  says  Doctor  Hyde, 
"could  be  transported  to  London  in  the  early 
part  of  the  present  century,  no  peculiarities  of 
architecture,  dress  or  behaviour  would  be  so  con- 
spicuous as  the  enormous  number  of  pockmarked 
faces  he  would  encounter  at  every  turn." 
The  comparative  frequency  of  pockmarked 
faces  is  shown  by  the  following  description  of  a 
criminal  issued  by  the  London  police  authorities 
in  1688:  "Thomas  Baily,  a  short,  burly  man, 
fair  and  fresh  coloured,  without  pock-holes,  fiat- 
nosed,  under  forty  years  old,  commonly  wears  a 
fair  perriwig,  and  useth  a  blue  as  well  as  a  red 
coat." 

Writing  in  1747,  Doctor  Black  said:  "Very 
few  of  the  human  species  escape  the  smallpox,  espe- 
cially in  populous  cities  and  towns  wherein  there 
is  always  lasting  variolous  fuel.  ...  A  mere 
handful  of  the  native  progeny  of  the  metropolis 
can  be  supposed  to  have  escaped  an  infection 
with  which  they  are  constantly  enveloped."  One 
hundred  years  ago  smallpox  was  the  most  wide- 
spread disease  which  afflicted  the  human  race. 
To-day  many  physicians  of  large  experience  have 
never  seen  a  case.  Communities  of  thousands  of 
inhabitants  pass  months  and  even  years  without 
its  occurrence.     No  sane  person  of  adult  years  can 


226  HOW   TO    KEEP    V/ELL 

read  history  without  beheving  that  some  marvelous 
power  has  been  at  work  to  produce  this  change. 
What  else  can  it  have  been  but  vadcination  ? 

It  will  surprise  many  to  know  that  in  former 
times  smallpox  was  essentially  a  disease  of  child- 
hood, more  than  80  per  cent,  of  all  cases  occurring 
in  children  under  five  years.  As  vaccination  is 
done  chiefly  in  infancy  and  childhood,  it  is  a  strong 
proof  of  its  efhcacy  that  it  has  been  transferred 
from  childhood  to  adult  life,  when  immunity  has 
been  exhausted. 

Let  us  now  consider  the  history  of  smallpox 
since  Jenner's  time  and  compare  it  with  previous 
conditions.  In  England,  it  has  been  estimated 
that  in  1660  the  average  annual  number  of  deaths 
per  million  from  smallpox  was  4,170.  Doctor 
Farr  estimated  the  rate  per  million  at  4,260  for 
the  thirty  years  from  1728  to  1757.  Official 
registration  of  the  causes  of  death  began  in  1838. 
From  that  year  to  1854,  a  period  of  optional 
vaccination,  the  average  rate  per  million  was  430. 
From  1854  to  1894,  a  period  of  enjoined  vacci- 
nation, the  rate  for  the  whole  period  w^as  140. 
From  1872  to  1894  the  laws  were  more  rigid, 
and  the  rate  was  86.  Excluding  the  epidemic 
of  1872,  it  was  but  53.  In  the  fourteen  years  pre- 
ceding 1872,  the  average  death  rate    from    small- 


VACCINATION  227 

pox  in  the  British  army  per  100,000  strength  was 
ii.i;  for  twenty-two  years  after  that  date,  3.7. 
This  was  rendered  even  higher  by  the  loss  in  1899 
of  twenty-three  men  in  India.  In  1895,  in  a 
population  of  more  than  4,000,000,  there  were  55  ' 
deaths  from  smallpox  in  London.  With  less  than 
one-fourth  that  population,  Sir  J.  Simon  states 
that  during  the  eighteenth  century  the  annual 
death  rate  of  smallpox  in  London  ranged  from 
3,000  to  5,000. 

Sweden  furnishes  some  particularly  valuable 
facts,  for  excellent  records  have  been  kept  since 
1774.  Between  1774  and  1901,  the  average  small- 
pox mortality  per  million  living  was  2 ,045.  During 
fifteen  years  (1802  to  18 16)  of  optional  vaccination 
the  average  mortality  was  408,  and  for  seventy- 
seven  years  of  compulsory  vaccination  it  averaged 
155.  During  the  ten  years  from  1884  to  1893 
(the  latest  record  I  can  obtain),  under  still  more 
rigid  laws,  there  was  no  year  in  which  the  rate 
per  million  was  above  5 ;  it  was  in  one  year  as  low 
as  .2.  In  the  twenty-eight  years  before  1801  the 
rate  was  more  than  1,000  in  eighteen  different 
years,  reaching  in  1779  the  enormous  figure  of 
7,196.  Since  1801  it  has  been  below  100  in 
forty-six  different  years,  and  below  10  in  fifteen 
different  years. 


228  HOW   TO    KEEP   WELL 

Attempt  has  been  made  by  anti-vaccinationists 
to  minimize  the  value  of  these  remarkable  figures 
by  the  theory  that  there  was  a  natural  decline  in 
smallpox  before  vaccination  had  been  adopted. 
The  facts  are,  however,  that  vaccination  was  taken 
up  in  Sweden  with  the  utmost  enthusiasm.  It  is 
known  that  in  1802,  eighty  physicians  had  lymph 
in  their  possession.  In  1804,  royal  orders  required 
vaccination  by  means  of  the  pastors  of  churches, 
while  in  the  following  year  the  Royal  College 
alone  reported  25,000  vaccinations.  It  certainly 
requires  great  credulity  to  believe  that  the  rapid 
fall  in  the  mortality  rate  from  2,045  "to  480  was 
due  to  a  change  in  the  character  of  the  disease. 

Prussia  also  affords  some  convincing  evidence 
of  the  efficacy  of  vaccination.  The  Prussian  army 
was  the  first  place  where  vaccination  was  required 
on  a  large  scale.  It  was  begun  in  1834,  and  during 
the  next  fourteen  years  there  were  but  77 
cases  of  smallpox  and  varioloid,  and  not 
one  death.  In  1843  an  epidemic  of  smallpox 
occurred  in  Prussia,  but  in  the  army  there  were 
but  12  cases.  During  the  Franco-German  War 
the  German  troops,  about  1,000,000  in  num- 
ber, were  well  vaccinated,  and  but  457  deaths 
occurred  from  smallpox.  In  the  imperfectly 
vaccinated    French    army,    on    the    other    hand, 


VACCINATION  229 

though  smaller  in  size,  there  were  23,400  deaths 
from  that  disease.  It  should  be  understood  that 
the  troops  from  the  other  States  making  up  the 
German  army  of  that  time  were  not  so  thoroughl}?- 
vaecinated  as  were  those  of  Prussia,  but  all  were 
vastly  better  vaccinated  than  were  the  French. 

Since  1874  a  much  more  rigid  vaccination  law 
has  been  in  force  in '  Germany.  Vaccination  of 
all  infants  is  made  compulsory,  with  revaccination 
at  school  age.  The  mean  death  rate  from  small- 
pox per  million  before  this  law  was  409 ;  since  the 
law  was  passed  it  has  been  1 5 ;  during  the  last  ten 
years,  7.  In  the  army,  in  which  the  vaccination 
law  is  most  strictly  enforced,  there  has  been  but 
one  death  from  smallpox  since  1874.  The  general 
rate  has  never  risen  materially  since  that  year. 
The  cases  that  have  occurred  have  been  largely 
upon  the  frontier  and  among  foreigners. 

These  figures  from  Prussia  have  given  the  anti- 
vaccinationists  much  perturbation  of  spirit  They 
have  been  able  to  get  around  them  only  by  actual 
untruth,  in  asserting  that  the  law  of  1835  was  a 
compulsory  vaccination  law.  That  law  urgently 
recommended  vaccination,  but  did  not  make  it 
compulsory.  Such  a  law  was  passed  only  in  1874. 
The  anti-vaccinationists  have  tried  to  explain 
the    diminished    death    rate    here,  as    in    Sweden, 


230  HOW   TO    KEEP   WELL 

upon  the  ground  of  improved  sanitation.  The 
argument  is  absurd.  There  was  no  sudden  im- 
provement in  the  sanitary  conditions  in  either 
country,  and  Prussia  and  Sweden  are  not  more 
sanitary  than  other  countries  where  there  has 
been  no  such  radical  change  either  in  the  occurrence 
or  mortahty  of  smallpox. 

In  Austria,  vaccination  is  not  compulsory,  and 
there  we  find  some  striking  facts  of  different 
character.  During  the  years  in  which  the  death- 
rate  from  smallpox  in  Prussia  was  7,  in  Austria  it 
was  458.  In  Belgium,  another  country  in  which 
vaccination  is  not  compulsory,  the  death  rate  per 
million  from  1875  to  1884  was  441,  when  Prussia's 
was  22.  Are  we  to  infer  that  Prussia  is  just  twenty 
times  as  sanitary  as  Belgium?  In  the  year  1886 
the  death  rate  from  smallpox  of  Switzerland  was 
fifty-fourfold  that  of  Germany;  that  of  Belgium, 
forty-eightfold;  Austria  eighty-onefold;  and  Hun- 
gary, six  hundred  and  sevenfold. 

In  Italy,  registration  of  causes  of  death  was 
initiated  in  1881.  A  compulsory  law  of  vaccina- 
tion in  infancy,  and  revaccination  of  all  the  children 
attending  public  schools,  was  instituted  in  1888. 
The  smallpox  deaths  per  100,000  inhabitants  from 
1 88 1  to  1890  averaged  35.5,  being  during  but  two 
years  below  20.      From  1891  to    1894  the  average 


VACCINATION  231 

was  6.5.  In  tlie  four  great  capitals  of  Europe,  in 
ten  years  from  1877  to  1886,  the  smallpox  deaths 
per  100,000  living  were  as  follows:  Vienna,  67; 
Paris,  28;  London,  25;  Berlin,  i. 

In  several  localities  in  England  a  strong  anti- 
vaccination  sentiment  has  arisen,  and  by  the  irony 
of  fate  these  towns  furnish  some  very  wholesome 
lessons.  In  the  Sheffield  epidemic  of  1887-88, 
we  have  the  following  statistics  as  given  by  the 
Practitioner: 

Attack  rate  per  i  ,000  in  non- vaccinated,       94 ;  death  rate  5 1 

"  "  "  once  vaccinated,       19;      "         "        i 

revaccinated,  3;     "         "  .08 

One  in  1,300  of  the  vaccinated  died;  one  in  20  of 
the  unvaccinated. 

In  Gloucester  the  anti-vaccination  sentiment 
had  been  particularly  strong,  and  in  the  epidemic 
of  1895-96  there  were  1,979  cases  and  439  deaths  in  a 
population  of  42,000.  Strenuous  attempts  were 
made  to  stay  the  epidemic  by  means  of  hospitals, 
disinfection,  and  quarantine,  without  the  slightest 
effect.  It  raged  unchecked  until  officials  who  had 
publicly  and  boastingly  declared  themselves  op- 
posed to  vaccination  became  panic-stricken  and, 
turning  directly  about,  enforced  the  vaccination 
laws.     The  epidemic  was  then  rapidly  quelled. 

Statistics  derived  from  armies  are  of  particular 


2^,2  HOW   TO    KEEP   AVELL 

value,  for  there  is  no  chance  for  the  concealment 
of  cases,  which  frequently  occurs  in  civil  life. 
Every  case  of  disease,  as  well  as  every  death,  is 
known.  Beginning  with  1874,  the  average  annual 
death  rate  per  100,000  strength  in  various  armies 
was  as  follows:  French  army  for  eight  years,  15; 
Austrian  army  for  six  years,  26;  British  army 
for  twenty  years,  3.7;  Prussian  army,  one  solitary 
death  from  1874  to  1896.  I  have  not  been  able 
to  obtain  the  statistics  since  that  3'^ear.  As  already 
stated,  vaccination  is  more  thoroughly  carried  out 
in  the  Prussian  army  than  among  any  other  like 
body  of  men,  the  British  army  standing  next. 

Smallpox  hospitals  also  furnish  their  evidence 
of  the  efficacy  of  vaccination.  Doctor  William  M. 
Welch,  in  an  experience  of  twenty-five  years  as 
physician  to  the  Municipal  Hospital  of  Philadel- 
phia, reports  that  no  physician,  nurse,  or  employee 
of  that  institution,  vaccinated  before  beginning 
duty,  ever  contracted  smallpox.  Doctor  Marson, 
physician  to  the  London  Smallpox  Hospital, 
said:  "In  thirty-five  years  I  have  never  had  a 
servant  or  nurse  with  smallpox;  I  revaccinate 
them  when  they  come  here."  In  his  classic 
article  based  upon  observations  made  upon  5,982 
patients,  he  reports  a  mortality  of  35.55  per  cent, 
in  patients  never  vaccinated,  and   5.25  per  cent. 


VACCINATION  233 

in  those  who  had  been  vaccinated  once  and 
showed  a  scar.  Doctor  ColUe  says  that  during  the 
epidemic  of  1871,  out  of  no  smallpox  attendants 
at  Homerton,  all  but  two  were  re  vaccinated,  and 
those  two  alone  took  smallpox.  Mac  Vail  collected 
statistics  of  1,500  smallpox  attendants,  forty-three 
of  whom  had  smallpox,  but  not  one  of  the  forty- 
three  had  been  revaccinated.  Doctor  Bracken, 
of  Minneapolis,  has  this  year  reported  662  cases 
of  smallpox,  but  ten  having  ever  been  vaccinated. 
Of  these  ten,  twenty  years  or  more  had  elapsed 
since  the  vaccination  in  seven. 

The  Chicago  Board  of  Health  has  recently  made 
the  following  statement:  "Out  of  a  total  of  171 
cases  of  smallpox  found  in  Chicago  between 
November  30,  1900,  and  April  10,  1901,  140  had 
never  been  vaccinated.  Of  the  remaining  thirty- 
one  cases,  twenty-nine  were  adults,  showing  faint, 
poor,  or  irregular  scars,  claimed  to  be  evidence  of 
attempted  vaccination  in  infancy  or  childhood, 
the  most  recent  being  twenty-three  years  old. 
Only  two  out  of  the  171  cases  exhibited  scars  of 
successful  vaccination."  Vaccination  was  made 
compulsory  in  the  Chicago  schools  in  1867.  From 
1867  to  1881  there  were  but  seventeen  cases  of 
smallpox.  After  1881  there  was  not  a  single 
case  for  ten  vears,   when  four  developed.     These 


234  HOW   TO    KEEP    WELL 

children  had  been  passed  on  fraudulent  certificates, 
as  neither  of  them  could  present  a  scar.  In  St. 
Paul,  between  May  i,  1899,  and  May  10,  1901, 
there  were  104  cases  of  smallpox.  Of  these,  but 
two  had  ever  been  vaccinated,  one  fifteen  and  one 
twenty  years  before.  Doctor  P.  M.  Hall,  of  Minne- 
apolis, treated  191  cases  between  January  7  and 
May  8,  1901.  In  one  only  could  signs  of  vacci- 
nation be  found.  Individual  experiences  of  this 
character  could  be  quoted  indefinitely. 

One  of  the  most  positive  demonstrations  of  the 
power  of  vaccination  has  recently  been  afforded 
by  experience  in  Porto  Rico.  In  October,  1898, 
smallpox  was  endemic;  in  December  it  was  epi- 
demic ;  in  January  it  had  lioneycombed  the  island ; 
in  February  there  were  more  than  3,000  recent 
cases,  and  the  disease  was  spreading  at  a  gallop. 
By  order  of  General  Henry  a''systematic  compulsory 
vaccination  was  begun.  This  was  carried  out  by 
the  medical  officers  of  the  army.  The  vaccination 
was  begun  simultaneously  in  all  parts  of  the 
island.  The  work  was  done  scientifically,  as  work- 
by  the  medical  corps  of  the  army  is  always  done, 
and  was  carefully  recorded.  In  a  population  of 
960,000,  more  than  860,000  were  vaccinated.  Of 
these,  87.5  per  cent,  were  successful.  The  work 
was  completed  July  ist.     The  average  number  of 


VACCINATION  235 

deaths  from  smallpox  in  the  ten  years  preceding 
that  date  was  621,  there  being  3,000  cases  when 
the  work  was  begun.  The  number  of  deaths  in 
the  two  and  one-half  years  following  that  date 
have  been  at  the  rate  of  two  per  annum.  This 
work,  scientifically  done  and  recorded  in  an 
island  under  military  control,  furnishes  abso- 
lutely authentic  data,  the  correctness  of  which 
cannot  be  questioned. 

Another  very  recent  demonstration  of  the 
effect  of  vaccination  is  that  afforded  by  Cleveland. 
Early  in  1902  the  Health  Officer  of  that  city  dis- 
continued vaccination,  and  announced  that  here- 
after he  would  rely  wholly  on  disinfection.  This 
action  was  taken  at  the  beginning  of  the  warm 
season,  just  as  an  epidemic  was  passing  away,  there 
being  but  twenty  cases  of  smallpox  in  the  city. 
The  disease  continued  to  diminish,  and  the  anti- 
vaccinationists  were  loud  in  their  assertion  that 
this  was  a  demonstration  that  disinfection  was  the 
only  safeguard  needed.  As  a  matter  of  fact, 
inflammable  material  was  thus  allowed  to  collect, 
to  be  ignited  at  the  first  spark  of  infection.  That 
result  came  sooner  than  might  have  been  expected. 
According  to  the  report  of  the  Marine  Hospital 
service  on  August  8,  1902,  there  was  and  had 
been  for  some  time  more  smallpox  in   Cleveland 


236  HOW   TO   KEEP   WELL 

than  in  any  other  city  of  the  country.  It  is  need- 
less to  say  that  pubHc  vaccination  has  been  resumed 
in  that  city. 

The  statement  is  frequently  made  that  small- 
pox has  become  a  much  milder  disease  than  it 
formerly  was,  and  that  vaccination,  therefore,  is 
less  necessary.  Facts  do  not  bear  out  this  state- 
ment. It  is  quite  true  that  during  the  recent 
epidemic  the  death  rate  in  some  localities  has  been 
extremely  low,  and  the  illness  has  been  mild.  It 
has,  however,  not  been  universally  so.  It  is 
true  of  all  epidemic  diseases,  that  the  prevailing 
type  varies  considerably  in  diiferent  years,  and 
smallpox  has  certainly  not  of  late  shown  itself  in 
its  most  virulent  forms.  Another  factor  is  to 
be  considered  as  accounting  for  its  mildness.  It 
is  not  noticeable  that  the  term  "varioloid"  is 
now  but  seldom  used.  All  attacks  are  now  called 
smallpox,  a  tendency  to  be  commended.  It  re- 
mains true,  however,  that  a  great  many  cases 
have  been  reported  as  smallpox  which  in  the  past 
would  have  been  described  as  varioloid.  In 
those  who  have  never  been  vaccinated,  the  disease 
in  most  epidemics  is  almost,  if  not  quite,  as  dan- 
gerous as  it  ever  has  been.  In  the  London  Small- 
pox Hospital,  between  1775  ^^^^  1800,  all  patients, 
of  course,  being  unvaccinated,  the  mortality  rate 


VACCINATION  237 

was  32.5  per  cent.  In  1853  Marson  found  that 
the  rate  of  the  previous  sixteen  years  was  35.55 
for  the  unvaccinated.  In  a  recent  study  of  small- 
pox, Welch  reports  1,512  cases  in  unvaccinated 
persons,  with  a  death  rate  of  more  than  58  per  cent. 
In  young  children  the  rate  was  much  higher  than 
this.  Hart  gives  the  death  rate  of  unvaccinated 
patients  as  fully  40  per  cent.  In  the  Sheffield 
epidemic  of  1887,  the  death  rate  was  51   per  cent. 

The  statement  sometimes  heard,  that  scarlet 
fever  is  as  dangerous  as  smallpox,  is  unwarranted. 
After  an  extensive  study  of  American  and  European 
cases,  Holt  states  that  the  general  death  rate 
from  scarlet  fever  is  from  12  to  14  per  cent.,  and 
from  20  to  30  per  cent,  under  five  years.  This 
is  less  than  half  the  most  favourable  rate  given 
for  smallpox.  The  sequels  of  scarlet  fever,  though 
often  grave,  are  not  to  be  compared  with  those  of 
smallpox.  A  hundred  years  ago  two-thirds  of 
the  inmates  of  the  blind  asylums  had  lost  their  sight 
from  smallpox.  Blindness,  deafness,  lung  disease, 
tuberculosis,  general  ruin  of  the  constitution,  and 
personal  disfigurement  are  the  common  results. 
In  fact,  the  ravages  of  the  disease  cannot  be 
estimated  by  the  number  it  kills. 

Under  our  form  of  government,  it  seems  almost 
impossible   to   hope  that   compulsory   vaccination 


238  HOW   TO    KEEP    WELL 

will  ever  be  attained  and  enforced.  The  dread  of 
abridging  the  personal  liberty  of  the  few  often 
leads  us  into  neglecting  the  rights  of  the  many. 
It  is  only  by  persistently  educating  succeeding 
generations  that  anything  like  adequate  vaccina- 
tion of  the  community  at  large  will  be  accom- 
plished. It  seems  also  that  the  lesson  must  occa- 
sionally be  enforced  l^y  the  bitter  experiences  of 
a  more  or  less  fatal  epidemic. 

Experience  of  more  than  a  century  has  con- 
firmed and  strengthened  the  teachings  of  Jenner, 
except  upon  the  single  point  of  the  duration  of 
immunity.  Some  of  the  lessons  taught  may  be 
summarized  as  follows. , 

1.  The  first  lesson  cannot  be  better  stated 
than  in  the  words  of  the  Berlin  Board  of  Health: 
"Vaccination  in  infanc}^,  renewed  at  the  end  of 
childhood,  renders  an  individual  practically  as 
safe  from  death  by  smallpox  as  if  that  disease  had 
been  survived  in  childhood,  and  almost  as  safe 
from  attack." 

2.  The  duration  of  immunity  conferred  by 
vaccination  is  variable.  In  many  individuals, 
vaccination  in  infancy  and  revaccination  in  child- 
hood is  sufficient  for  life  protection.  In  a  limited 
number  immunity  is  lost  after  five  or  six  years. 
It  is  never  possible  to  know  with  certaint}^  to  which 


VACCINATION  239 

class  an  individual  belongs.  In  the  face  of  an 
epidemic,  therefore,  vaccination  of  all  who  have 
not  been  vaccinated  within  five  or  six  years  is 
giving  what  the  lawyers  call  the  benefit  of  a  reason- 
able doubt.  Every  one  who  has  been  vacci- 
nated in  infancy  and  childhood  should  be  vacci- 
nated not  less  than  once  in  adult  life. 

3.  The  immunity  conferred  by  vaccination  is 
in  direct  proportion  to  the  thoroughness  with 
which  it  is  performed,  and  this  is  shov/n  with 
considerable  accuracy  by  the  character  and  num- 
ber of  resulting  scars. 

4.  The  mild  compulsion  enforced  in  this  coun- 
try, by  requiring  vaccination  or  evidence  of  its 
recent  performance  upon  admission  to  the  public 
schools,  should  have  the  hearty  support  of  parents 
and  physicians  alike. 

The  statistics  and  facts  pertaining  to  the  history 
of  smallpox  and  vaccination  recorded  in  the 
foregoing  pages  were  derived  from  the  following 
sources,  where  every  statement  may  be  verified: 

Reports  of  the  Royal  Commission  on  Vaccination, 
London. 

Edward  Jenner.  Works,  particularly  the  "In- 
quiry," published  in  1798. 

E.  J.  Edwards  and  others.  Jenner  Centenary 
Number  of  the  Practitioner.     London,  May,  1896. 


240  HOW   TO    KEEP   WELL 

J.  F.  Marson.  Medico-Chirurgical  Transactions. 
London,  Vol.  XXXVL 

F.  S.  Fielder.  Vaccination  Clinically  Consid- 
ered.    The  Medical  News,  March  30,  1901. 

E.  C.  Seaton.  "Handbook  of  Vaccination." 
London,   1868. 

P.    Brouardel.     "Twentieth    Century  Practice," 

Vol.  xin. 

W.  M.  Welch.  A  Statistical  Record  of  5,000 
Cases  of  Smallpox.  New  York  Medical  Journal, 
March  17  and  24,  1894. 

Journal  of  tJic  American  Medical  Association, 
August  3,  1 90 1. 

The  Medical  News,  April  19,  1902. 


CHAPTER  VIII 

The  Effect  of  Modern  Life  Upon  Disease 
The  diseases  of  a  people  are  modified  from  gen- 
eration to  generation  by  the  changing  habits  of  life, 
and  never  have  such  radical  changes  taken  place 
as  those  in  this  country  during  the  past  half  cen- 
tury. From  a  community  largely  agricultural, 
with  no  large  cities,  population  has  trebled,  and 
the  country  has  developed  into  a  great  commercial 
and  manufacturing  nation.  Until  the  present 
generation  of  active  workers,  the  chief  task  of  the 
American  people  was  the  subduing  of  the  continent. 
The  American  spent  his  life  out-of-doors.  On  the 
frontier,  which  but  yesterday  disappeared,  his  life 
was  rough  and  vigorous,  and  one  of  constant  physi- 
cal endeavour.  In  the  wake  of  the  frontier  were 
the  long  stretches  of  farms  and  rural  communities, 
followed  later  by  ranches  and  mining  camps,  all 
demanding  the  life  of  physical  toil  and  open-air 
labour.  This  work  of  continent  subduing  began 
the  day  the  Puritans  landed  in  New  England  and 

the  Cavaliers  in  Virginia,  and  did  not  cease  until 

241 


242  HOW   TO    KEEP   WELL 

the  Pacific  had  been  reached.  For  two  hundred 
and  fifty  years  the  young  men  and  women  of  the 
country  left  the  older  regions  of  the  East  in  yearly 
swarms,  as  bees  leave  the  parent  hive.  Ever  push- 
ing westward,  they  developed  a  race  as  hardy  and 
vigorous  as  ever  conquered  savage  or  tilled  the  soil. 
Whoever  says  the  American  is  not  a  hardy  race 
ignores  facts. 

In  the  meantime  it  had  become  a  homogeneous 
people.  Until  1820  immigration  was  slight,  and 
rarely  exceeded  6,000  a  year.  During  the  next 
twenty-five  years  the  average  yearly  immigra- 
tion was  little  more  than  42,000.  About  1847, 
however,  a  sudden  change  occurred,  and  the  yearly 
arrivals  have  since  been  counted  by  hundreds  of 
thousands,  at  times  approaching  the  half -million 
mark.  These  foreign  peoples  have  penetrated 
into  the  remotest  localities,  carrying  with  them 
their  own  physical  peculiarities  and  diseases. 

Vast  cities  have  come  into  existence,  and  to-day 
there  are  several  in  what  was  the  frontier  of  fifty 
years  ago  that  are  larger  than  was  the  metropolis 
of  that  day.  Overcrowding  in  the  centres  of  popu- 
lation has  become  the  rule.  New  York  enjoys  the 
bad  distinction  of  possessing  several  of  the  densest 
populated  acres  in  the  world.  An  overcrowded 
population  carries  with  it  its  own  diseases.     Many 


THE    EFFECTS    OF    MODERN    LIFE  243 

of  the  diseased  conditions  seen  by  the  physicians 
of  pubhc  dispensaries  and  hospitals  are  either 
unknown  in  well-to-do  private  practice  or  appear 
in  radically  different  form. 

Overcrowding  shows  its  effects  in  the  well-to-do 
portions  of  large  cities  as  well  as  in  the  tenement 
regions.  The  tendency  to  gregariousness  is  seen 
everywhere.  The  farmer  leaves  tho  farm  and  goes 
into  the  village,  where  his  mode  of  life  materially 
changes.  It  becomes  less  active,  if  not  actually 
sedentary.  In  this  he  illustrates  the  whole  ten- 
dency of  modern  life  among  the  better-to-do;  the 
abandoning  of  ph^^sical  labour  and  the  adoption  of 
callings  v/hich  less  and  less  require  an  out-of-door 
life  and  manual  labour.  Agriculture  and  manu- 
facturing are  done  more  and  more  by  machinery. 
The  labourer  in  these  fields  becomes  less  a  labourer 
and  more  a  passive  attendant  upon  a  machine. 
The  young,  both  men  and  women,  seek  the  factory, 
the  shop,  the  store,  the  business  office,  the  profes- 
sions, and  the  vast  army  of  sedentary  people 
becomes  more  vast  year  by  year. 

These  changes  are  to  a  certain  degree  world-wide, 
but  in  no  other  country  have  they  been  so  rapid 
as  in  America.  From  a  largely  agricultural  people 
with  scarcely  a  suggestion  of  a  leisure  class,  we  are 
becoming  a  cosmopolitan    nation  with    a  steadily 


244  HOW   TO    KEEP   WELL      • 

increasing  leisure  class.  Added  to  this  is  the  tre- 
mendous tension  under  which  our  newly  found 
tasks  are  being  done.  Here  we  have  fruitful 
sources  of  new  diseases  and  modifications  of  the  old. 
In  the  matter  of  adapting  themselves  to  new 
conditions,  the  intelligent  are  sometimes  but  little 
in  advance  of  the  less  intelligent  masses.  People 
are  just  beginning  to  learn  that  new  conditions  of 
life  demand  new  methods  of  living,  that  sedentary- 
lives  within  brick  walls  are  producing  effects  which 
their  grandfathers  never  experienced.  They  are 
beginning  to  see  that  a  few  months  of  modern  com- 
mercial life  are  more  exhausting  than  were  as  many 
years  of  the  old  village  life  of  the  North  or  the  plan- 
tation life  of  the  South.  Golf  and  tennis  would 
have  been  absurdities  in  Colonial  times,  for  the 
people  did  too  much  physical  labour.  The  regular 
summer  vacation  or  a  tramp  in  the  mountains 
was  then  unnecessary,  for  the  people,  even  of  the 
cities,  walked  or  rode  horseback  most  of  the  time. 
The  men  of  old  computed  their  business  in  thou- 
sands; they  walked  home  at  noon  and  ate  dinner 
in  a  rational  way.  ,  They  required  few  vacations. 
The  men  of  to-day  compute  their  business  in 
millions;  they  eat  that  abomination  known  as  a 
"quick  lunch,"  and  employ  a  labour-saving 
machine  called  a  typewriter  which  enables  them 


THE    EFFECTS    OF    MODERN    LIFE   245 

to  write  six  times  as  many  letters  a  day,  and  thus 
load  their  mental  faculties  with  six  times  as  much 
business. 

Golf,  tennis,  and  the  bicycle,  as  well  as  outings 
and  summer  vacations,  are  expressions  of  a 
rational  appreciation  that  the  times  have  changed. 
The  tendency  to  get  back  to  the  land,  to  become 
more  intimate  with  the  country,  and  escape  from 
the  city  for  a  part  of  the  year,  is  constantly  becom- 
ing stronger.  It  is  doing  much  to  neutralize  the 
evils  which  necessarily  result  from  the  crowding 
of  the  population  into  vast  cities.  Three  or  four 
decades  ago  only  a  few  of  the  wealthiest  Americans 
living  in  the  cities  owned  homes  in  the  country. 
Now  such  a  home  is  by  no  means  an  indication  of 
great  wealth.  Thousands  of  families  of  moderate 
means  have  a  little  home  in  the  country,  a  cottage 
at  the  seashore,  or  a  camp  in  the  mountains  to 
which  they  go  early  and  return  late.  The  tendency 
shown  by  all  classes  to  escape  from  the  cities  for  a 
part  of  the  year  is  a  fortunate  and  beneficent  one. 

While  there  has  been  a  more  or  less  marked 
decrease  in  the  frequency  of  almost  every  disease 
during  the  past  twenty-five  years,  three  classes  of 
diseases  have  increased.  These  three  classes  are: 
fatty  degenerations,  kidney  disease,  and  cancer. 
Myocarditis,  or  degeneration  of  the  heart  muscle, 


246  HOW   TO    KEEP   WELL 

has  increased  150  per  cent.,  while  the  population 
has  increased  but  50  per  cent.  Disease  of  the 
arteries,  which  is  degenerative  in  nature,  has 
markedly  increased.  Certain  forms  of  Bright's 
disease  have  almost  doubled.  The  power  of 
alcohol  in  the  form  of  malt  liquors  to  produce 
degenerative  changes  is  so  well  known  to  patholo- 
gists, that  the  conclusion  is  irresistible  that  the 
radical  increase  in  these  diseases  comes  largely 
from  changed  drinking  habits.  Certain  conditions 
which  result  from  the  excessive  use  of.  distilled 
liquors  have  not  increased.  Cirrhosis  of  the  liver, 
long  known  as  "gin-drinker's  liver,"  has  relatively 
diminished.  This  disease  is  usually  the  result  of 
the  excessive  use  of  whisky  or  brandy.  Since  1883, 
with  an  increase  in  the  population  of  about  50  per 
cent.,  the  consumption  of  distilled  spirits  has 
increased  but  30  per  cent.  It  is  impossible  to 
adequately  consider  the  diseases  of  a  people  with- 
out considering  their  drinking  habits,  for  alcohol- 
ism is  one  of  the  most  important  predisposing 
causes  of  many  forms  of  disease. 

Between  1890  and  1900  the  census  shows  a 
decrease  in  the  following  diseases  per  100,000 
population:  consumption  from  245  to  190;  diar- 
rheal diseases  from  104  to  85;  diphtheria  from 
70.1  to  35.4;  typhoid  fever  from  46  to  :^t,;  mem- 


THE    EFFECTS    OF    MODERN    LIFE  247 

branous  croup  from  27  to  9;  malarial  fever  from 
19  to  8.  An  increase  is  shown  in  the  following 
diseases:  pneumonia  from  186  to  191 ;  heart  disease 
from  121  to  134;  kidney  disease  from  59  to  83; 
apoplexy  from  49  to  66;  cancer  from  47  to  60; 
diabetes  from  5  to  9. 

Americans  are  not  intemperate  as  a  people. 
Statistics  all  show  that  their  consumption  of  beer, 
wine,  and  spirits  is  comparatively  small.  Bence- 
Jones  says  that,  with  the  exception  of  Canada,  the 
consumption  of  alcohol  in  the  United  States  is  the 
smallest  of  any  large  nation.  In  1890  the  con- 
sumption of  spirits  per  head  was  1.17  gallons;  in 
1898  it  had  fallen  to  .92  of  a  gallon.  AVhile  the 
use  of  beer  had  increased,  it  was  but  thirteen 
gallons  per  year  per  head.  At  the  same  time  it 
was  thirty-two  gallons  in  Great  Britain,  twenty- 
seven  gallons  in  all  Germany,  and  fifty-six  gallons 
in  Bavaria.  Schooling  has  recently  presented 
statistics  in  which  he  shows  that  the  use  of  wine 
and  spirits  in  America  is  small,  while  the  use  of 
beer  is  not  half  that  of  German}^  and  England. 
He  believes  that  the  alertness  and  prompt  energy 
of  the  American  may  be  due  in  part  to  this  rela- 
tive abstinence  from  alcoholic  drink.  The  most 
serious  aspect  of  the  drink  problem  in  this  country 
is  the  increasing  tendency  to  drink  to  excess  shown 


248  HOW   TO    KEEP   WELL 

by  the  women  of  the  more  intelligent  and  educated 
classes.  What  will  be  the  future  of  a  people  whose 
mothers  are  drunken  ? 

The  immigration  of  beer-drinking  peoples  will 
result  in  the  increased  average  consumption  of  beer 
in  the  future,  and  will  teach  our  people  the  same 
habit.  The  brewing  industries  of  this  country  need 
the  close  supervision  they  have  in  Germany.  Much 
of  the  beer  sold  is  so  adulterated  that  it  is  unfit  to 
put  into  the  human  body.  Indeed,  the  same  is  true 
of  much  of  the  wine  and  brandy,  and  even  the 
whisky,  sold  in  shops  and  saloons. 

There  are  interesting  contrasts  in  the  compara- 
tive vitality  of  the  sexes.  Symonds,  of  New  York, 
has  recently  made  a  study  of  the  statistics  obtained 
by  life  insurance  companies.  He  confirms  Farr's 
statement  that  women  have  a  greater  expectation 
of  life  at  every  age  than  men.  During  the  first 
year  female  mortality  is  decidedly  less  than  the 
male.  Altliough  more  boys  are  born  than  girls, 
the  great  mortality  among  them  reduces  the  pro- 
portionate number  to  a  balance  in  favour  of  the 
females.  When  he  is  five  years  old  a  boy  goes  out- 
of-doors  more.  The  girl,  in  the  meantime,  is  kept 
in  the  house,  and  her  mortality  begins  to  rise,  and 
for  a  time  passes  that  of  the  boy.  The  ten  years 
between    forty-five    and    fifty-five    is    commonly 


THE    EFFECTS    OF    MODERN    LIFE  249 

regarded  as  a  critical  period  for  women.  The 
actual  increase  in  mortality,  however,  is  not  more 
than  in  previous  years.  On  the  other  hand,  the 
male  mortality  rises  rapidly  during  this  period. 
Between  fifty-five  and  sixty  the  female  mortality 
increases,  but  after  this  age  the  two  rates  run 
along  in  parallel  lines,  the  female  being  always  less 
than  the  male.  Insurance  tables  also  show  that  the 
largest  number  of  deaths  in  men  occur  between  the 
fortieth  and  fiftieth  years  of  life;  the  next  largest 
number  between  the  fiftieth  and  sixtieth  years. 
The  large  mortality  rate  at  this  period  of  life  is  the 
logical  result  of  twenty-five  years  of  struggle  in 
business  or  professional  life.  The  overstrenuous 
life  untempered  by  reason  cannot  continue  in- 
definitely. 

The  diseases  that  have  been  brought  most  com- 
pletely under  control  by  improved  treatment  and 
sanitary  measures  are  not  those  of  middle  life, 
unfortunately  for  the  individual  who  has  reached 
that  age.  Medical  science  has  done  much  to  make 
life  safe  up  to  the  age  of  twenty.  Mortality  during 
the  first  five  years  is  always  high,  but  has  been 
greatly  lowered.  During  the  second  five  years  it 
suddenly  diminishes.  From  ten  to  fifteen  it  is 
lower  than  at  any  other  period  of  life.  From 
fifteen  to  twenty  it  is  but  little  higher.     At  twent^^ 


250  HOW    TO    KEEP   WELL 

however,  the  individual  must  begin  the  race  with 
disease.  At  first  he  may  meet  with  typhoid  fever, 
tuberculosis,  pneumonia,  acute  rheumatism,  dys- 
pepsia, and  appendicitis.  At  forty-five  he  enters 
upon  the  period  of  greater  tendency  to  heart 
disease,  kidney  disease,  cancer,  diabetes,  alcohol- 
ism, digestive  diseases,  chronic  rheumatism,  and 
gout.  A  little  later  he  enters  the  period  of 
arterial  diseases,  apoplexy,  and  certain  degen- 
erative changes. 

At  every  age  life  may  be  cut  short  by  the 
destructive  forces  utilized  by  modern  civilization. 
A  man  may  be  electrocuted  by  live  wires  in  the 
streets,  or  hurled  to  destruction  by  dynamite.  He 
may  be  smothered  in  a  fire-proof  hotel,  or  dashed 
to  death  in  a  falling  elevator.  He  may  be  run 
over  by  bicycles,  trolley  cars,  or  automobiles,  or 
crushed  in  a  railway  accident.  These  causes  of 
death  have  an  appreciable  effect  upon  the  mortal- 
ity tables.  According  to  the  reports  of  the  Inter- 
state Commerce  Commission,  during  the  ten  years 
ending  1900,  68,837  people  were  killed  on  the  rail- 
roads of  the  United  States,  and  387,803  were 
injured.  Many  cases  were  probably  not  reported. 
And  this  is  but  one  mode  of  accident.  After  forty- 
five,  death  by  accident  becomes  relatively  more 
common.     In   fact,   after  that  age  statistics  show 


-    THE    EFFECTS    OF    MODERN    LIFE  251 

that  a  man  is  twice  as  liable  to  die  from  accident 
as  from  old  age.  In  later  life  accident  is  one  of  the 
common  causes  of  death. 

Another  cause  of  death,  more  frequent  now  than 
it  was  formerly,  is  suicide.  Between  1890  and 
1900  the  ratio  per  100,000  population  in  the  fifty 
largest  cities  of  this  country  increased  from  12 
to  16.6.  The  Mutual  Life  Insurance  Company 
reports  that  the  proportion  of  suicide  to  all  deaths 
has  increased  from  1.9  per  cent,  to  2.4  per  cent,  in 
the  last  fifty  years.  The  popular  impression  that 
the  loneliness  of  farm  life  induces  suicide  is  dis- 
proved by  the  fact  that  the  rate  for  large  cities 
was  16.6  while  that  of  the  whole  country  was  11.8. 
It  is  a  curious  fact  that  the  frequency  of  suicide 
varies  greatly  in  different  cities.  In  the  decade 
ending  in  1900  it  ranged  from  31.1  per  100,000  in 
San  Francisco  to  23.3  in  Chicago,  15.4  in  Boston, 
13.6  in  New  York,  5.1  in  Trenton,  and  2.9  in  Fall 
River.  Among  the  large  European  cities,  Paris 
stands  first  in  the  number  of  suicides,  the  rate 
being  42,  while  that  of  Berlin  is  36,  Vienna  28, 
London  23,  Rome  8,  St.  Petersburg  7,  and  Madrid 
3.  Among  the  foreign  countries  the  highest  rate 
is  in  Saxony,  where  it  is  31.1,  that  of  Austria  being 
21.2,  France  15.7,  Prussia  13.5,  and  England  6.9. 
In  the  forty-five  largest  American  cities,  between 


252  HOW   TO    KEEP   WELL 

1890  and   1900,  there  was  a  total  of  15,144  known 
suicides. 

There  can  be  but  little  doubt  that  the  historian 
of  the  future  will  look  back  to  the  nineteenth  cen- 
tury as  a  marvelous  one.  One  of  the  notable 
facts  which  will  attract  his  attention  will  be  the 
remarkable  increase  in  the  population  of  the  civil- 
ized world.  It  is  estimated  that  during  the  century 
the  world's  population  increased  from  950,000,000 
to  1,558,000,000.  This  increase  was  confined  to 
the  civilized  countries  and  those  coming  directly 
under  their  influence.  It  is  a  common  error  on 
this  side  of  the  Atlantic  to  believe  that  America  is 
the  only  country  that  has  shown  a  great  increase 
of  population.  When  AA^illiam  the  Conqueror 
landed  in  England  in  1068  he  found  a  population 
in  that  country  and  Wales  of  but  2,150,000. 
During  six  hundred  years  the  population  but 
little  more  than  doubled,  and  as  late  as  1800 
numbered  but  8,500,000.  In  1900  it  had  increased 
to  about  32,500,000.  The  population  of  Germany 
increased  from  24,800,000  in  1816  to  53,300,000  in 
1900.  The  population  of  Japan  has  increased 
14,000,000  since  1870,  and  similar  changes  are 
shown  in  other  countries.  The  only  country  of 
Europe  which  has  shown  an  actual  diminution 
of  population  is  Ireland. 


THE    EFFECTS    OF    MODERN    LIFE   253 

Increase  in  population  may  result  from  three 
causes,  acting  alone  or  together — increased  birth 
rate,  decreased  death  rate,  immigration.  While 
immigration  has  aided  in  increasing  the  population 
of  America  and  Australia,  it  has  tended  to  diminish 
that  of  Europe.  A  study  of  vital  statistics  soon 
shows  that  throughout  the  civilized  world  there 
has  been  during  the  past  half  century  not  only  a 
decrease  in  marriages,  but  also  a  decrease  in  the 
number  of  births  per  marriage.  That  is,  the  birth 
rate  has  visibly  diminished.  This  means  that  the 
remarkable  increase  in  the  population  must  have 
been  the  result  of  a  diminished  death  rate.  This 
is  confirmed  by  vital  statistics.  Wherever  modern 
civilization  has  gone,  there  has  followed  a  decrease 
in  the  death  rate  and  an  increase  in  the  population. 
During  the  eighteenth  century  the  annual  death- 
rate  per  1,000  of  population  was  nowhere  under 
50;  it  was  often  70  or  80.  In  1900  the  average 
death  rate  for  the  "registration"  cities  of  the 
United  States  was  18.6.  In  1620  the  death  rate  in 
London  per  i  ,000  was  more  than  70,  and  the  average 
duration  of  life  was  but  fifteen  years,  owing  in 
part  to  the  enormous  infant  mortality.  In  the  next 
one  hundred  and  fifty  years  the  average  duration 
of  life  increased  but  four  years.  In  1835  ^^^ 
death  rate   had   fallen   to  32    per    1,000,   and  the 


254  HOW   TO    KEEP    WELL 

duration  of  life  had  increased  to  almost  thirty 
years,  and  has  become  much  longer  since.  In  the 
United  States  the  average  age  at  death  in  1890 
was  3 1. 1  years.  In  1900  it  was  35.2  years.  These 
are  but  a  few  facts  to  show  how  diseases  have 
changed  under  the  influence  of  sanitary  and 
medical  science. 

Three  hundred  years  ago  almost  twice  as  many 
people  died  every  year  in  London  from  .smallpox, 
plague,   dysentery,   and   cholera   as  now   die   from 
all  causes  combined.     These   diseases,   as  well  as 
typhus    fever,    leprosy,    and    yellow    fever,   may 
almost    be    called    extinct    diseases    in    civilized 
countries.     Combined,  they  form  but  an  insignifi- 
cant fraction  of  the  mortality  rate.     Deaths  from 
diphtheria,  typhoid  fever,  malarial  fever,  and  the 
summer    diseases    of    children   have   been   greatly 
reduced    during    the    past    decade.     Tuberculosis 
remains  as  the  greatest  destroyer  of  human  life, 
for  it   causes   fully   one-fourth   of   all  the  diseases 
and  deaths  at  the  most  important  period  of  life, 
from  fifteen  to  fifty  years.     It  is  the  diseases  against 
which  sanitarians  are  directing  their   most   active 
efforts,  and  their  labours  have  already  borne  fruit. 
When  we  consider  the  financial  aspect  alone  of  the 
loss  of  so  many  valuable  lives,  the  indifference  of 
legislators     and     their     disinclination     to     expend 


THE    EFFECTS    OF    MODERN    LIFE   255 

money   to   aid   in   suppressing  tuberculosis   seems 
very   strange. 

About  one  hundred  years  ago  Malthus  promul- 
gated the  doctrine  that  population  naturally 
increases  in  a  geometrical  ratio,  while  the  means  of 
subsistence  increases  only  in  an  arithmetical  ratio. 
He  further  held  that  vice  and  crime,  wars  and 
cataclysms,  epidemics  and  plagues  are  the  measures 
adopted  by  nature  to  restrict  population  within 
safe  bounds.  The  Malthusian  doctrine  was  quite 
generally  accepted  by  political  economists  of  the 
early  nineteenth  century.  Its  overthrow  in  the 
latter  half  of  the  century  is  perhaps  more  apparent 
than  real.  It  still  holds  true  of  uncivilized  nations. 
Civilization  has  not  only  been  followed  by  increased 
population,  but  thus  far  by  increased  prosperity. 
Not  only  has  wealth  increased,  but  the  wages  of 
labour  have  increased  during  the  last  half  of  the 
century,  in  some  countries  as  much  as  133  per  cent. 
and  even  more.  The  people  of  the  civilized  world 
live  far  better  to-day  than  they  did  a  century  ago. 
These  results  have  been  due  to  causes  which 
Malthus  could  not  have  foreseen.  He  could  not 
know  of  the  evolution  of  modern  science  and  its 
application  to  the  relief  of  human  wants,  especially 
in  the  production  of  food.  Commercial  expansion 
has    made    the    food    products    of   remote    regions 


256  HOW   TO   KEEP   WELL 

available.  Steam  and  electricity  have  brought 
the  granaries  of  the  world  to  the  very  gates  of  the 
great  cities.  Otherwise  they  could  not  exist. 
Equity  and  justice,  and  the  elevation  of  moral 
standards,  have  reduced  crime  and  pauperism,  and 
removed  certain  causes  of  early  death.  Improved 
sanitation,  and  the  increased  efficiency  of  medical 
science,  have  also  produced  results  that  could  not 
have  been  foreseen  a  century  ago.  Smallpox  alone 
caused  60,000,000  deaths  in  Europe  during  the 
eighteenth  century,  and  the  victims  were  largely 
children. 

One  of  the  most  certain  indications  of  the  civiliza- 
tion of  a  people  is  the  care  it  bestows  upon 
infancy  and  childhood.  The  attention  devoted 
to  the  management  of  infants  and  the  rearing  and 
education  of  children  is  a  marked  characteristic  of 
modern  civilization.  It  has  resulted  in  a  large 
saving  of  child  life,  and  has  been  no  small  factor  in 
bringing  about  increase  in  population.  The  eman- 
cipation and  elevation  of  womanhood  was  another 
characteristic  feature  of  nineteenth  century  civiliza- 
tion, and  resulted  in  increased  material  prosperity. 
It  was  a  necessary  preliminary  to  the  improved 
care  of  children.  "The  hand  that  rocks  the  cradle 
rules  the  world."  More  intelligent  care  on  the 
part  of  the  mothers  has  been  a  factor,  not  alone 


THE    EFFECTS    OF    MODERN    LIFE  257 

in  saving  the  lives  of  infants,  lnit  in  rearing  them 
to  sturdy  manhood  and  womanhcjod.  The  "ad- 
vanced woman"  of  recent  times  does  some 
foolish  things,  and  does  not  always  use  her  new- 
found liberty  judiciously,  but  her  general  influence 
has  been  for  good,  and  she  has  been  an  active  agent 
in  advancing  civilization.  Her  influence  has 
always  been  thrown  on  the  side  of  improved  sanita- 
tion and  hygiene,  and  she  is  ever  a  valuable  aid  in 
carrying  out  the  measures  of  preventive  medicine. 

The  people  of  to-day  are  more  temperate  than 
they  were  a  century  ago,  and  thus  another  cause 
of  disease  and  abbreviated  life  is  reduced.  Total 
abstinence  is  now  demanded  of  employees  by 
thousands  of  employers  and  great  corporations. 
Never  before  in  history  has  strict  temperance  been 
practised  by  so  large  a  portion  of  the  population  of 
a  great  nation  as  in  the  United  States  to-day. 
Finally,  preventive  medicine  has  had  a  large  and 
honorable  share  in  setting  at  nought  the  cruel  and 
pitiless  doctrine  of  Malthus. 

A  great  decrease  has  recently  been  shown  in 
some  of  the  most  prevalent  diseases  of  large  cities. 
Infant  mortality  must  always  be  large,  but  the 
improvement  shown  during  the  last  forty  years 
is  extraordinary.  During  the  first  eight  years 
after  the  organization  of  the  Health  Department  of 


258  HOW   TO    KEEP   WELL 

New  York  in  1866  it  averaged  123.3  in  each  thou- 
sand children.  This  has  steadily  fallen  to  64.8,  a 
decrease  of  almost  50  per  cent.  In  1866  the  death 
rate  for  the  contagious  diseases,  tuberculosis,  and 
diarrheal  diseases  was  13.2  per  thousand.  It  fell 
to  but  1 1.8  for  ten  years  preceding  1883,  but  has 
since  decreased  to  6.4,  a  diminution  of  more  than 
50  per  cent.  These  results  are  due  to  several 
causes,  the  most  important  probably  being  the 
diminished  death  rate  from  diphtheria  due  to  the 
use  of  antitoxin,  decrease  in  the  occurrence  of 
tuberculosis,  and  a  marked  decrease  in  the  occur- 
rence of  the  summer  diarrheas  of  children.  Much 
has  been  accomplished  by  improved  methods  of 
treatment,  better  methods  in  the  care  of  children, 
and  of  those  suffering  from  contagious  diseases, 
an  improved  milk  supply,  cleaner  streets,  and 
improved  conditions  in  many  tenement  regions. 

A  study  of  life  tables  recently  made  by  Roger 
S.  Tracy,  of  the  New  York  Board  of  Health,  proves 
that  a  child  born  to-day  has  an  expectation  of  life 
nearly  four  years  longer  than  the  child  born  fifty 
years  ago  had.  This  increased  expectation  contin- 
ues during  the  early  years  of  childhood.  It  then 
gradually  diminishes,  until  at  thirty-five  it  is  vir- 
tually the  same  as  that  of  the  older  period.  After 
the  age  of  forty  or  forty-five  it  becomes  actually 


THE    EFFECTS   OF    MODERN    LIFE    259 

less,  and  a  man  at  this  age  has  a  less  expectation  of 
life  than  did  his  grandfather. 

These  strange  facts,  it  has  been  suggested,  are 
due  to  two  causes.  First,  the  saving  of  child  life 
undoubtedly  throws  forward  into  adult  life  a  cer- 
tain number  of  weakly  individuals  who  succumb 
at  middle  age  in  the  struggle  for  existence.  This 
is  probably  counteracted,  however,  by  the  better 
condition  in  which  the  average  modern  child  enters 
upon  life,  owing  to  wiser  methods  of  care.  Second, 
as  to  the  expectation  of  life,  after  middle  age,  the 
strain  of  existence  is  becoming  constantly  greater 
and  has  a  visible  effect.  There  is,  besides,  a  grow- 
ing tendency  in  many  grades  of  societ}^  toward  self- 
indulgence  and  neglect  of  methods  of  right  living. 
"Few  people,"  says  Tracy,  "have  enough  self- 
control  to  become  centenarians."  There  are, 
moreover,  certain  contagious  diseases  which  are 
becoming  more  prevalent  in  this  country. 

Two  very  important  facts  are  brought  out  by 
the  statistics  just  presented — the  saving  of  life  in 
its  early  stages  and  the  sacrificing  of  life  in  its  later 
stages.  These  must  be  due  to  well-defined  causes. 
If  so  many  infant  lives  may  be  saved,  it  is  the  duty 
of  parents  to  make  themselves  familiar  with  the 
helpful  methods.  If  the  lives  of  the  middle-aged 
are  being  unnecessarily  sacrificed,  as  thev  certainly 


26o  HOW   TO    KEEP   WELL 

are,  it  is  the  duty  of  the  individual  to  ascertain  the 
causes  and  endeavour  to  avoid  them.  In  the  pages 
that  follow  I  have  endeavoured  to  throw  some  light 
on  both  these  subjects. 


CHAPTER    IX 

The  Rearing  of  Children 

"It  is  babyhood  that  has  made  man  what  he 
is,"  says  John  Fiske.  This  is  a  concise  statement 
of  a  most  important  fact.  To  man  of  all  animals 
has  been  granted  the  longest  period  of  development, 
during  which  he  is  plastic  and  capable  of  being 
moulded.  Not  only  is  the  developmental  period 
actually  the  longest,  with  but  one  or  two  possible 
exceptions,  but  relatively  it  is  far  the  longest. 
Even  if  a  man  attain  his  full  span  of  threescore 
and  ten  years,  a  full  third  of  it  must  be  devoted 
to  development  and  preparation  for  the  other 
two-thirds.  The  difference  between  man  and 
the  lower  animals  is  admirably  shown  by  Fiske  in 
his  illustration  of  the  codfish.  "Its  acts  are 
mostly  concerned  with  the  securing  of  food  and 
the  avoidance  of  danger.  These  acts  are  few 
in  kind,  and  require  for  their  performance  a  very 
slight  intelligence.  Its  experiences,  while  numer- 
ous enough,  are  so  much  of  a  kind  that  practically 
they   require    only  the    monotonous    repetition    of 

the  same  few  acts.     So  few  are  these  acts,  and  so 

261 


262  HOW   TO    KEEP   WELL 

limited  the  nervous  connections  necessary  to  their 
proper  performance,  that  they  become  established 
by  heredity,  and  the  young  codfish  enters  upon  its 
life  capable  of  performing  all  of  them  about  as 
well  as  its  ancestors.  It  has  little  to  learn  by 
experience.  It  requires  no  education.  It  has  no 
infancy." 

As  we  ascend  in  the  scale  of  animal  life,  we 
reach  a  grade  of  development  which  cannot  be 
fully  attained  before  birth.  It  must  be  largely 
gained  by  growth  and  education  after  birth. 
This  period  we  call  infancy.  Another  illustration 
of  Fiske's  is  admirable  in  making  clear  this  point. 
"The  young  puppy,"  he  says,  "is  quite  helpless 
at  birth.  But  his  infancy  is  short,  and  he  soon 
crystalizes  into  an  adult  dog.  Yet  short  as  is  the 
infancy  of  this  species,  dog-fanciers  have  taken 
advantage  of  it,  and  by  careful  training  and  selec- 
tion have  developed  many  interesting  varieties  of 
this  animal.  These  men  fully  recognize  that  the 
period  of  infancy  is  that  of  plasticity,  for  they 
say,  'It  is  hard  to  teach  old  dogs  new  tricks.' 
The  acts  of  the  adult  animal  of  this  species  are 
so  simple  that  a  short  infancy  is  all  that  is  neces- 
sary to  gain  the  experience  and  adjust  the  nervous 
connections  required  for  the  performance  of  the 
adult  acts." 


THE    REARING    OF    CHILDREN       263 

As  we  go  higher  in  the  scale,  we  find  that  the 
greater  the  intelligence  and  the  more  complete 
the  life  the  longer  is  the  period  of  infancy.  The 
manlike  apes  of  the  highest  order  are  helpless  at 
birth,  and  have  an  infancy  of  considerable  length. 
Coming  to  man,  we  find  that  at  least  twenty-five 
years  are  necessary  for  the  attainment  of  full 
physical  and  mental  development.  The  State,  in 
regarding  its  citizens  as  "infants"  until  the  age 
of  twenty-one  years,  is  certainly  not  demanding 
too  much. 

While  this  slow  development  is  true  of  the 
physical  man,  it  is  doubly  true  of  the  mental  man. 
There  is  a  peculiar  asymmetry  between  his  normal 
mental  and  physical  development.  At  one  year 
of  age,  the  infant  possesses  almost  two-thirds 
the  brain  substance  of  the  adult,  but  the  functional 
capacity  is  not  the  one-hundreth  part  of  what  it 
will  be  after  twenty  years  of  education  and  experi- 
ence. At  ten  years  the  brain  has  attained  almost 
its  full  size,  and  it  is  not  uncommon  to  see  a  boy 
of  that  age  who  is  able  to  wear  his  father's  hat. 
But  long  years  of  education  must  follow  before 
he  can  be  entrusted  with  his  father's  business 
or  professional  affairs.  And  that  power  will 
not  come  by  itself;  it  is  not  inborn.  It  must  be 
developed. 


264  HOW   TO    KEEP   WELL 

To  what  practical  point  does  this  lead,  and  what 
does  it  teach  ?  It  presents  the  very  real  fact  that 
a  tremendous  responsibility  is  placed  upon  every 
parent  upon  the  birth  of  a  child.  This,  happily,  is 
fully  appreciated  by  the  majority  of  American 
parents,  and  it  is  unnecessary  to  add  to  the  weight 
of  that  feeling  of  responsibility.  But  the  most 
conscientious  may  make  errors.  The  mistake  is 
often  made  in  believing  too  much  in  inheritance 
and  the  power  of  heredity.  There  are  very  few 
natural  Little  Lord  Fauntleroys.  It  should  not  be 
forgotten,  moreover,  that  the  winning  qualities  of 
that  attractive  little  character  were  supposed  to  be 
due  only  in  part  to  inheritance  from  his  gentle- 
manly father.  They  were  far  more  the  result  of 
the  careful  training  of  a  devoted  and  very  clever 
mother.  That  touch  of  nature  was  a  stroke  of 
true  genius,  both  in  the  book  and  its  dramatic 
presentation.  Inherited  capacity  for  a  generous 
and  noble  life,  developed  by  persistent  training 
by  a  mother  capable  of  appreciating  and  living 
such  a  life  herself,  made  the  character  what  it 
was.  That  little  book,  commonly  classed  as  a 
children's  book,  might  receive  a  sub-title,  "A 
Guide  for  Parents." 

An  error  in  the  training  of  children,  not  uncom- 
mon, but  always  fatal  when  it  occurs,  is  the  belief 


THE    REARING   OF   CHILDREN       265 

that  a  child  will  possess  certain  qualities  of  charac- 
ter naturally  and  without  training.  Because 
a  child  is  of  gentle  stock  it  does  not  necessarily 
follow  that  he  will  be  a  gentleman,  giving  to  that 
term  the  American  meaning.  The  only  safe 
course  is  to  begin  young  and  train  him  persistently 
in  the  ways  of  true  gentility.  "Born  gentlemen" 
are  rare  in  this  world.  Most  of  those  who  pass 
by  that  name  were  trained  infants.  Courtesy, 
polish,  tact,  and  knowledge  of  social  and  worldly 
ways,  are  necessary  to  a  gentleman.  They  are 
the  superficial  evidences  which  upon  first  acquaint- 
ance are  the  most  apparent.  But  in  addition  to 
this,  a  real  gentleman  is  unselfish,  thoughtful  for 
others,  honourable,  generous,  and  kind.  But  these 
qualities  must  be  developed  during  the  first  years 
of  life  or  in  many  cases  they  will  never  develop. 
Honour  and  generosity,  as  opposed  to  deceit, 
indirection,  shiftiness,  and  meanness,  are  qualities 
that  can  be  vastly  increased  by  precept  and  ex- 
ample. Unselfishness,  and  regard  for  the  comfort 
as  well  as  the  rights  of  others,  are  qualities  that  can 
be  developed  or  repressed  by  training  more  than 
almost  any  others.  The  most  generous  nature 
can  be  rendered  absolutely  selfish  by  training. 
The  parents  who  habitually  sacrifice  themselves 
wholly  to  the  child,  and  make  the  whole  house- 


266  HOW   TO    KEEP   WELL 

hold  subservient  to  him,  are  deUberately  educat- 
ing him  to  selfishness  and  meanness.  Much  more 
selfishness  is  created  in  this  world  by  training 
than  is  born  into  it. 

Who  can  know  the  whole  importance  of  those 
first  plastic  years  ?  The  teachings  of  those  years 
can  never  be  wholly  eradicated.  We  speak  of 
our  inborn  religious  beliefs.  They  were  mostly 
instilled  into  us  by  our  mothers  before  we  were 
fairly  out  of  our  cradles.  In  nothing  does  the 
Catholic  Church  show  its  wisdom  more  clearly, 
and  its  knowledge  of  human  nature,  than  in  its  care 
for  the  young.  Put  a  child  under  devout  Catholic 
influence  during  its  first  half  dozen  years,  and 
it  is  always  a  Catholic.  The  fundamental  princi- 
ples you  implant  in  yonv  child  during  those  3^ears 
will  form  the  basis  of  his  character  thereafter. 
What  you  train  him  to  be  during  his  first  fifteen 
years,  that  he  will  be  to  the  end  of  his  life.  He 
will  develop  and  grow,  perhaps,  beyond  all  expec- 
tation; he  will  outgrow  some  characteristics,  and 
change  in  others;  he  may  take  some  sudden  turn 
which  you  in  your  blindness  did  not  expect;  but 
with  few  exceptions  the  character  he  has  at  sixteen 
he  will  carry  with  him  through  life. 

The  meaning    of    heredity  is  largely    misunder- 
stood.    Much  less  is  inherited  than  many  people 


THE    REARING   OF    CHILDREN       267 

suppose.  A  ca[yacity  is  inherited  which  is  capable 
of  development  by  education,  experience,  or 
observation.  Paderewski  must  certainly  have  an 
innate  ability  as  a  pianist.  He  probably  inherited 
a  capacity  for  that  art,  but  he  did  not  inherit  the 
art  he  possesses  to-day.  His  natural  capacity 
has  been  developed  by  unremitting  toil  such 
as  few  artists  have  been  willing  to  undergo. 
And  thus  it  is  with  most  talents  which  lead  to 
success  in  life.  In  the  vast  majority  of  cases 
they  must  be  developed.  An  occasional  genius 
succeeds  without  much  training,  but  a  genius  is  an 
anomaly,  and  an  exception  to  all  rules.  The  rule 
is,  that  an  inborn  talent,  to  be  of  any  value  to  its 
possessor,  must  be  developed  and  expanded 
during  the  formative  years  of  life. 

The  discrepancy  between  the  physical  and 
mental  growth  in  man,  to  which  reference  has 
already  been  made,  is  far  less  noticeable  in  the 
lower  animals.  The  nervous  S3^stem  of  the  child 
is  normally  immature,  and  incapable  of  doing  sus- 
tained mental  work  without  injury.  The  child 
that  deviates  from  the  physiological  condition  by 
showing  remarkable  mental  precosity  is  an  abnor- 
mal child,  and  one  that  must  be  carefully  and 
tactfully  restrained  if  the  best  mental  and  phys- 
ical   development    is  to  be  hoped  for.     The  young 


268  HOW   TO    KEEP   WELL 

of  birds  and  certain  animals  are  very  precocious; 
they  care  for  themselves  within  a  few  days,  and 
reach  their  full  development  within  a  few  weeks. 
As  we  go  higher  in  the  scale  of  development,  the 
young  are  less  precocious.  In  the  higher  monkey 
tribes,  it  requires  from  six  to  ten  years  to  reach 
full  mental  and  intellectual  development.  In 
certain  of  the  African  faces  the  span  of  life  is 
thirty  years.  The  children  of  these  savages  are 
very  precocious;  they  walk  early,  and  reach  phys- 
ical and  intellectual  development  at  about  ten 
years.  Many  Negro  children  are  phenomenally 
precocious,  while  Caucasian  infants  of  civilized 
countries  are,  mentally,  the  least  precocious  of  all 
creatures. 

Precocity  may  result  from  a  number  of  causes, 
and  may  be  divided  into  more  or  less  distinct 
types,  the  recognition  of  which  is  important  in 
the  care  and  training  of  children.  Two  types  are 
particularly  referred  to  by  Doctor  Rachford,  who 
has  made  an  extended  study  of  this  subject. 
In  the  first  of  these  are  those  precocious  children 
of  good  physique,  who  have  inherited  from  an 
intellectual  parentage  unusually  active  nerve 
centres.  This  form  of  mental  precocity  may  be 
associated  with  good  physical  development.  Such 
children  are,  as  a  rule,  encouraged,  or  at  least  not 


THE    REARING   OF    CHILDREN       269 

discouraged,  and  as  a  result  the  mental  functions 
are  forced  into  a  premature  maturity,  which  does 
not  conduce  to  intellectual  vigour  in  after  years. 
They  live  in  an  intellectual  atmosphere  much  above 
their  years,  and  do  not,  as  a  rule,  delight  in  the 
sports  of  children  of  their  own  age.  If  properly 
guarded  and  restrained  during  childhood,  such 
children  are  capable  of  the  highest  intellectual 
development  in  after  life;  they  can  be  moiilded 
into  the  highest  type  of  symmetry,  or  they  can 
be  dwarfed,  by  excessive  intellectual  activity,  into 
mental  mediocrity. 

In  the  second  class  are  the  precocious  children 
of  an  altogether  different  type.  These  are  chil- 
dren of  poor  physique,  who  have  inherited  physical 
weakness  or  actual  disease.  They  are  often  of 
gouty  or  tuberculous  families,  frail  of  body  and 
fair  of  skin,  beautiful  and  bright-eyed.  They 
are,  as  a  rule,  affectionate,  lovable,  and  mentally 
precocious.  But  their  delicacy  of  constitution 
is  such  that  they  are  incapable  of  sustained  intel- 
lectual effort.  Their  precocity  is  fitful,  and  lacking 
in  symmetry.  It  is  common  for  them  to  have  a 
remarkable  memory,  which  is  developed  at  the 
expense  of  their  other  mental  faculties.  The  child 
mathematicians,  poets,  and  musicians,  as  a  rule, 
belong  to  this  class.     Early  in  life  they  exhaust 


270  HOW    TO    KEEP   WELL 

their  mental  energy  in  the  development  of  a  single 
faculty,  and  then  lapse  into  mediocrity.  Precocious 
children  of  this  type  need  intelligent  restraint 
and  direction  throughout  the  whole  period  of 
childhood.  The  chief  aim  in  the  management 
of  such  children  should  be  the  improvement  of 
the  physical  and  the  restraint  of  the  intellectual 
development. 

The  rearing  of  children  involves  the  great  ques- 
tion of  education,  which  means  something  far  more 
than  schooling.  Herbert  Spencer  mentions  five 
objects  to  be  attained  in  the  education  of  children: 
that  education  which  prepares  for  direct  self- 
preservation;  for  indirect  self-preservation;  for 
parenthood ;  for  citizenship ;  for  the  miscellaneous 
refinements  of  life. 

Direct  self-preservation  is  the  most  important 
lesson  which  a  child  should  learn.  By  the  knowl- 
edge he  learns  to  take  care  of  himself  and  to  pro- 
tect himself  from  injury  and  disease.  A  child 
who  always  has  a  nurse  or  governess  at  its  elbow 
meets  with  as  many  accidents  as  one  who  is  obliged 
to  take  care  of  himself.  He  fails  to  learn  the  im- 
portant lesson  of  self-preservation.  The  education 
which  prepares  for  indirect  self-preservation  con- 
sists in  the  mastery  of  that  knowledge  which  is 
necessary  in  gaining  a  livelihood.     This  is  regarded 


THE    REARING   OF   CHILDREN       271 

by  many  as  the  moSt  important  object  of  educa- 
tion, and  is  too  often  considered  the  only  object. 
It  has  been  overdone  in  recent  years.  The 
education  which  prepares  for  parenthood  is  clearly 
of  the  utmost  importance  to  the  future  well-Vjeing, 
not  only  of  the  individual,  but  of  the  race,  and  is 
almost  universally  neglected.  The  fourth  division, 
which  includes  the  teaching  of  political  and  moral 
science,  is  universally  acknowledged  to  be  of  great 
importance.  Yet  it  is  often  neglected  in  colleges 
and  higher  schools.  In  a  country  where  the 
government  is  vested  in  the  peojole,  its  importance 
is  especially  great.  The  last  division  has  too 
often  been  permitted  to  usurp  the  time  which 
might  be  devoted  to  other  objects  to  better  advan- 
tage. Some  schools  and  colleges  have  made  it 
almost  the  sole  object  of  their  efforts.  This  is 
happily  becoming  less  true  in  this  country.  The 
pendulum  has,  in  fact,  been  in  some  cases  allowed 
to  swing  too  far  in  the  other  direction.  In  the 
effort  to  render  education  "practical,"  that 
training  which  develops  culture  and  refinemen  t  has 
been  neglected.  That  education  is  unquestion- 
ably best  which  best  enables  the  individual  to 
protect  himself  and  gain  a  competent  livelihood, 
at  the  same  time  preparing  him  for  the  important 
duties  of  parenthood  and  citizenship  and  enabling 


272  HOW   TO    KEEP   WELL 

him  to  appreciate  and  enjoy  those  refinements  of 
hfe  which  Hghten  and  brighten  the  daily  toil  to 
which  most  of  us  are  assigned  by  destiny. 

The  rearing  of  children  is  easy  only  in  books. 
The  writing  of  a  chapter  like  this,  therefore,  is  an 
easy  task.  The  actualities  to  which  it  refers 
are  practically  very  difficult.  They  may  be  made 
a  little  less  difficult,  perhaps,  by  some  suggestions 
from  a  medical  practitioner  whose  duties  take  him 
day  by  day  within  the  inner  circle  of  many  families, 
where  he  must  needs  observe  the  successes  and  the 
errors  that  are  made  in  the  management  of  chil- 
dren. The  successes,  he  is  bound  to  say,  have, 
in  his  experience,  outnumbered  the  failures.  In 
view  of  the  difficulties  of  rearing  children  in  great 
cities,  the  results  attained  are  remarkably  good. 
The  good  mothers  far  outnumber  the  poor  ones. 
Errors  result  almost  universally  from  lack  of 
experience,  not  from  lack  of  desire  to  do  the  best. 
Among  the  well-to-do  the  indifferent  and  careless 
mother  is  very  rare.  The  chief  exceptions  to  this 
rule  are  found  among  those  women  who  make 
society  the  first  object  of  their  lives,  and  become 
overwhelmed  with  its  cares  and  duties.  To  the 
statement  sometimes  heard,  that  the  modern 
mother  is  growing  indifferent  to  her  children,  I 
would    enter    a    vigorous  protest.     It  is  not  true. 


THE    REARING    OF    CHILDREN       273 

The  mother  of  to-day  is  what  tlie  mother  has  been 
in  all  time — devoted,  loving,  and  true,  ever  ready 
to  sacrifice  her  own  comfort  for  her  child,  and  to 
place  its  interests  before  her  own.  Errors  are 
largely  those  of  inexperience  or  of  judgment,  not  of 
indifference  or  wrong  intent. 

The  fact  is  often  forgotten  that  the  mother 
of  to-day  has  a  much  more  difficult  task  than  had 
her  grandmother.  Under  the  simple  conditions 
in  which  our  grandparents  and  great-grandparents 
lived,  the  rearing  of  children  was  an  easier  task 
than  it  is  under  the  complex  civilization  of  to-day. 
We  are  not  at  fault  for  this,  but  must  take  things 
as  we  find  them  and  make  the  best  of  them,  even 
if  our  grandmothers  criticize  our  way  of  doing  it. 
We  were  born  into  this  modern  life  and  are  but 
units  in  its  great  rushing  current.  We  can  no 
more  stop  it  or  change  it  than  w^e  can  stop  the  flow 
of  the  river  by  damming  back  a  few  of  its  drops. 
We  are  here  in  the  midst  of  changing  conditions, 
We  have  ourselves  suffered  as  well  as  profited  by 
them;  and  our  children,  unforttmately,  must  suffer 
as  well  as  profit  by  the  changes  that  have  occurred 
since  our  childhood. 

It  cannot  be  demonstrated  that  the  parental 
training  of  to-day  is  inferior  to  that  of  the  past. 
Many  of  the  most  prevalent  errors  are  due  to  the 


274  HOW    TO    KEEP   WELL 

times  and  the  changed  conditions  of  life.  As  a 
matter  of  fact,  children  are  receiving  far  more  atten- 
tion and  rational  care  than  they  formerly  did.  To 
the  student  of  sociology,  one  of  the  most  notable 
features  of  the  past  few  decades  is  the  growing 
attention  bestowed  upon  children.  The  thought 
now  devoted  to  them  would  have  amazed  our 
.ancestors  of  three  generations  ago.  Thousands  of 
men  and  women  are  being  trained  in  normal 
schools  for  the  one  purpose  of  instructing  the  young, 
for  the  work  of  the  teacher  is  now  believed  to  be 
one  demanding  extensive  and  peculiar  education. 
Volumes  are  written  annually  for  children  and  of 
children,  wdiile  journals  and  magazines  of  the 
same  character  have  increased  a  hundredfold. 
The  children  are  considered  a  far  more  important 
factor  in  every  family  than  they  were  fifty  years 
ago. 

This  tendency  to  bestow  more  attention  upon 
children,  and  more  thought  upon  their  care  and 
education  and  training,  is  not  to  be  criticized,  but 
it  cannot  be  denied  that  the  matter  in  many 
families  is  carried  to  an  injudicious  extreme. 
Neither  can  it  be  denied  that  the  general  tendency 
is  in  the  direction  of  bringing  the  children  into  too 
great  prominence,  in  making  them  the  most  impor- 
tant   and    first -to-be-considered   members    of   the 


THE    REARING    OF    CHILDREX       275 

family,  and  in  laying  burdens  upon  them  too  great 
for  their  strength.  These  errors  are  undoubtedly 
greater  in  the  cities  and  large  towns,  where  the  high 
tension  of  life  is  felt  by  all  sorts  and  conditions 
of  men,  by  children  and  adults  alike.  An  error  is 
made  by  some  parents  in  making  comrades  of 
their  children  in  too  literal  a  sense.  There  is  a 
growing  tendency  to  remove  the  barriers  between 
childhood  and  age.  This  naturally  results  in  the 
feeling  that  the  children  should  enjoy  the  same 
pleasures  and  indulge  in  the  same  pastimes  as 
their  elders.  Such  recreation  is  of  a  character  too 
stimulating  for  the  sensitive  nervous  organism  of 
the  child.  It  cannot  fail  to  cause  harmful  effects 
during  childhood,  and  frequently  produces  a 
neurasthenic  and  nervous  temperament  in  later 
life.  When  a  child  becomes  a  man  he  should, 
assuredly,  put  away  childish  things,  but  it  is 
unkind  to  compel  him  to  do  so  while  he  is  still  a 
child.  This  is  the  frequent  fate,  however,  of  only 
children. 

"There  is  a  large  class  of  parents,"  says  Artemus 
Ward,  "who  have  an  uncontrollable  passion  for 
taking  their  children  where  they  will  stand  a  chance 
of  being  frightened  to  death."  The  carelessness 
of  many  parents  in  permitting  their  children  to 
see   and   hear    things   that    w411   harrow   up   their 


276  HOW   TO    KEEP   WELL 

souls  and  freeze  their  young  blood  is  truly  mar- 
velous. It  is  often  due  to  carelessness,  pure  and 
simple,  or  to  obtuseness  and  failure  to  appreciate 
the  feelings  of  a  nervous  child.  The  study  of 
animal  life  is  to  be  encouraged,  but  to  take  an 
impressionable  child  to  see  hideous  and  grotesque 
animals  or  loathsome  reptiles  is  the  refinement  of 
cruelty.  The  little  one  dreads  them  by  day  and 
dreams  of  them  by  night,  until  some  new  terror 
takes  the  place  of  the  old.  Even  the  Jungle  Books 
are  capable  of  doing  harm  to  a  nervous  child. 
Forcing  a  frightened  child  into  the  surf  may  far 
more  than  counteract  the  good  resulting  from  a 
visit  to  the  seashore.  These  are  but  illustrations 
of  many  instances  in  which  children  are  frightened 
unnecessarily.  Even  if  the  cause  seems  trivial,  it 
is  simply  cruelty  to  force  a  child  into  places  where 
it  will  certainly  be  terrified.  It  is  not  the  way  to 
make  a  child  courageous  or  brave,  but  will  almost 
infallibly  have  the  opposite  effect.  The  effects 
of  such  frights  upon  the  nervous  system  are  often 
most  disastrous.  Many  an  attack  of  feverishness 
and  mild  illness  of  obscure  origin  could  be  explained 
by  this  cause  could  the  doctor  always  know  the 
facts. 

"The  vast  army  of  neurasthenics  and  hysterics 
which     now    inhabit     our     cities,"     says     Doctor 


THE    REARING    OF    CHILDREN       277 

Rachford,  "is  yearly  being  increased  by  subjecting 
the  immature  nervous  systems  of  young  children 
to  the  almost  constant  excitement,  strain,  and 
mental  activity  with  which  our  social  order  has 
surrounded  them."  The  whole  period  of  infancy 
and  childhood  is  one  of  preparation  for  the  duties 
of  adult  life.  It  is  the  desire  of  every  parent  that 
his  child  mature  with  a  vigorous  body  and  mind. 
Many  of  the  conditions  of  modern  life,  however, 
tend  directly  to  frustrate  these  wishes.  Too 
often  the  parents,  instead  of  aiding  their  child 
to  become  the  strongest  possible  man,  do  what 
will  produce  the  opposite  result.  The  seeds  of 
"neurasthenia"  are  frequently  planted  years  before 
the  child  is  born,  and  he  enters  the  world  with  an 
irritable  nervous  system.  Stim.ulation  begins  at 
the  outset  when  every  opportunity  is  utilized  to 
pla}^  with  the  baby.  This  is  frequently  done  with 
so  much  vigour  that  the  child  is  rendered  tired  and 
nervous,  for  children  have  nerves  as  well  as  adults. 
Many  a  delicate  infant  is  made  sleepless  and  irri- 
table by  excessive  fondling  and  tossing  about. 
Though  it  seems  a  hardship,  it  is  frequently  neces- 
sary to  forbid  all  play  and  frolicking  with  an  infant. 
Every  child,  in  fact,  is  better  without  it;  an  infant 
does  not  need  to  be  amused. 

As  the  baby  grows  older  and  intelligence  grad- 


278  HOW   TO    KEEP   WELL 

ually  develops,  the  tendency  to  overstimulation 
becomes  stronger.  The  more  delicate  the  child, 
the  greater  the  harm.  The  parents,  impressed  with 
the  extraordinary  mental  capacity  of  their  descend- 
ant, frequently  do  serious  injury  in  their  anxiety  to 
develop  the  mental  processes.  Thus  far  it  has  been 
a  question  of  entertaining  the  parents  rather 
more  than  of  amusing  the  child.  A  little  later  the 
question  of  actual  amusement  of  the  child  arises, 
and  the  matter  is  often  seriously  overdone.  People 
forget  that  the  world  is  fresh  and  new  to  the  child, 
and  has  not  yet  become  old  and  stale.  They  forget 
that  the  child's  capacity  of  thought  and  compre- 
hension is  extremely  small.  The  young  child  is 
interested  in  the  most  simple  and  trivial  things, 
and  it  is  an  unkindness  to  force  complex  and 
difficult  amusements  upon  him.  The  amuse- 
ment of  young  children  is  largely  derived  from 
toys  and  playthings.  The  character  of  their  toys, 
therefore,  is  of  importance  even  in  the  case  of 
healthy  children. 

One  of  the  most  noticeable  peculiarities  of  child- 
hood is  a  tendency  to  become  attached  to  certain 
things  and  cling  to  them  most  persistently.  The 
young  child  loves  certain  nursery  songs,  and 
never  tires  of  hearing  the  mother  sing  them  over 
and   over.     He   loves   certain   stories,  and  listens 


THE    REARING   OF    CHILDREN       279 

with  minute  attention  to  their  hundredth  repeti- 
tion. He  becomes  attached  to  certain  toys,  and 
persistently  goes  back  to  them  in  preference  to 
new  and  handsomer  ones,  and  cUngs  to  the  old 
dilapidated  doll  in  preference  to  the  most  gorgeous 
new  one.  All  this  is  common  knowledge  to  every 
observer  of  children. 

An  explanation,  or  a  partial  explanation,  is  not 
difficult  to  reach.  A  child's  mental  capacity  is  as 
yet  undeveloped,  and  his  comprehension  is  very 
small.  He  knows  and  appreciates  the  old  familiar 
doll  and  its  few  clothes.  The  new  one,  with  its 
closing  eyes  and  jointed  limbs,  and  its  complex 
and  elaborate  dress,  is  beyond  his  small  compre- 
hension. It  tires  him  as  much  to  investigate  it 
and  unravel  all  its  mysteries  as  it  does  the  lawyer 
father  to  master  an  intricate  case.  So  he  returns 
to  the  old  one,  that  he  loves  and  comprehends 
without  effort.  If  the  child  is  content  with  simple 
toys,  why  force  upon  him  those  that  he  does  not 
love  so  much  ?  Why  not  follow  the  plain  teaching 
of  nature,  and  allow  him  to  pass  his  early  childhood 
in  the  most  simple  and  contented  manner  possible  ? 
It  is  true  that  he  can  be  educated  out  of  these 
simple  tastes,  too  often  at  the  expense  of  his 
own  contentment  and  the  happiness  of  those 
about  him.     When  he  has  once  formed  tastes  for 


28o  HOW   TO    KEEP   WELL 

less  simple  amusements,  he  cannot  be  forced 
back  into  the  old  ways  of  life.  If  he  becomes 
accustomed  to  a  multitude  of  toys  and  a  mob  of 
dolls,  and  dail}^  expects  something  new,  the  time 
will  come  when  his  requirements  cannot  be  filled. 
He  has  tried  and  become  tired  of  every  amusement 
adapted  to  his  own  age  and  of  that  far  in  advance 
of  it,  and  he  becomes  a  burden  to  all  about  him. 
The  most  contented  and  quiet  children  that  the 
physician  sees  in  his  rounds  are  not  those  with  the 
most  playthings. 

Mental  development  is  gradual,  and  is  not  of 
sudden  growth.  The  infant  outgrows  his  rattle 
and  ring,  and  the  young  child  gradually  grows 
beyond  his  simple  toys.  But  there  are  then  more 
elaborate  playthings,  and  these  in  turn,  as  child- 
hood advances,  give  place  to  books  and  games. 
Each  period  of  childhood,  youth,  and  age  has  its 
appropriate  amusements.  The  child  under  judi- 
cious management  passes  from  one  stage  to  another, 
and  need  not  lack  for  entertainment  from  the  cradle 
to  old  age.  It  is  doing  him  a  wrong  to  force 
upon  him  amusements  beyond  his  age,  and  to 
coerce  him  into  pleasures  which  properly  belong  to 
later  years. 

There  is  certainly  a  growing  tendency  to  engen- 
der in  children  a  taste  for  amusements  which  are 


THE   REARING   OF   CHILDREN       281 

too  complex,  which  overburden  the  mental 
faculties,  overstimulate  the  imagination,  and 
overtax  the  physical  powers.  Happiness  in  this 
world  results  from  contentment,  and  contentment 
cannot  exist  when  desires  and  longings  are  not 
satisfied.  Fortunate,  then,  is  that  child  who  has 
been  reared  with  simple  tastes,  is  content  with 
simple  amusements,  and  has  not  been  satiated  with 
all  the  pleasures  of  life  before  he  has  reached  man- 
hood. A  youth  with  simple  tastes,  and  with 
something  yet  to  learn  and  to  enjoy,  is  far  inore 
apt  to  develop  into  successful  and  contented 
manhood  than  he  who  has  early  been  forced  to 
feel  that  all  is  flat,  stale,  and  unprofitable. 


CHAPTER   X 

The    Diet    of    Children 

The  feeding  of  young  children  is  yearly  becom- 
ing a  problem  of  greater  importance,  for  the 
number  who  require  artificial  feeding  is  constantly 
increasing.  The  ability  of  mothers  to  nurse  their 
children  is  certainly  diminishing.  There  is  in 
some  quarters  an  undoubted  tendency  to  shun 
this  paramount  duty  of  motherhood,  though  in 
my  own  experience  this  statement  has  found  little 
confirmation.  Decreasing  maternal  nursing  is 
largely  the  result  of  inability  rather  than  disin- 
clination. When  it  is  not  possible,  the  mother 
does  wrong  to  blame  herself.  It  is  often  the  result 
of  no  fault  upon  her  part,  but  rather  of  the  times 
and  conditions  in  which  she  lives.  When  it  is  pos- 
sible for  a  mother  to  nurse  her  child  it  is  her  duty 
to  do  so.  The  infant  has  certain  inalienable  rights. 
He  is  entitled  to  the  best  food  and  the  best  care 
his  parents  can  give  him,  and  is  defrauded  if  he 
does  not  get  them.     It  goes  without  saying  that 

the  best  food  is  that  supplied  by  nature,  the  food 

282 


THE    DIET    OF    CHILDREN  283 

upon  which  so  many  generations  have  thrived. 
It  should  not  be  taken  from  an  infant  except  for 
the  most  weighty  reasons. 

A  potent  means  of  retaining  the  natural  food 
supply,  and  thereby  preventing  illness  in  the  infant, 
is  the  mother's  own  care  of  herself  and  her  diet. 
She  should  have  a  simple  but  generous  diet, 
because  the  secreting  of  thirty  or  forty  ounces 
of  milk  a  day  is  equivalent  to  hard  physical  labour. 
It  should  be  a  varied  diet,  and  should  not  consist 
in  too  large  measure  of  one  class  of  food.  Meat, 
milk,  eggs,  and  well-cooked  cereals  should  all  be 
included  in  rational  amounts.  While  milk  is 
admirably  adapted  to  her  special  needs,  and  should 
be  used  freely,  the  mother  should  avoid  an  exclu- 
sively liquid  and  sloppy  diet.  She  should  know 
that  her  mental  condition  is  of  as  much  importance 
as  her  diet.  Ungoverned  nerves  and  fits  of  temper 
are  more  harmful  to  the  child  than  any  ordinary 
indiscretions  in  eating.  She  should  avoid  a  life  of 
excitement  as  far  as  possible.  By  far  the  most 
important  rule  of  conduct,  both  for  herself  and  the 
little  one,  is  regularity.  Regularity  in  feeding,  and 
regularity  in  all  the  details  of  life,  are  so  important 
that  their  neglect  may  make  maternal  nursing 
impossible  where  it  might  otherwise  be  perfectly 
easy.     Irregularity,    bad    habits    of   nursing,    and 


284  HOW   TO    KEEP    WELL 

uncontrolled  nerves  are  among  the  principal  pre- 
ventable causes  of  the  prevailing  frequency  of 
artificial  feeding. 

The  subject  of  the  artificial  feeding  of  infants 
has  grown  in  importance  as  its  frequency  has 
increased.  So  important,  in  fact,  has  it  become, 
that  it  has  received  the  attention  and  profound 
study  of  some  of  the  best  minds  of  the  medical  pro- 
fession. Great  improvements  have  been  effected 
within  the  past  ten  years,  and  the  results  are 
already  apparent.  The  modern  saving  of  child 
life  has  been  due  in  no  small  measure  to  more 
rational  methods  of  feeding.  While  differences  of 
opinion  exist  regarding  some  of  the  details,  upon 
essential  points  there  is  great  unanimity  among 
those  whose  opinion  is  of  most  value.  The  first 
and  most  essential  point  upon  which  opinions  do 
not  differ  is  that  the  best  artificial  food  is  cow's 
milk.  No  other  food  will,  in  the  end,  be  as  well  for 
the  baby.  It  is  quite  true  that  there  are  certain 
objections  to  it,  and  certain  difficulties  in  it^  use. 
It  is  not  to  be  expected  that  any  artificial  food  will 
be  wholly  free  from  drawbacks  or  as  completely 
satisfactory  as  is  the  natural  food.  But  those 
objections  are  far  less  serious  in  milk  than  in  any 
other  form  of  artificial  food.  Some  of  the  prepared 
foods  are  easily  digested  by  some  children,  but  we 


THE    DIET    OF    CHILDREN  285 

must  not  fix  our  attention  upon  the  jjiesent  so 
closely  as  to  forget  the  future.  We  should  con- 
sider the  remote  as  well  as  the  immediate  effects 
of  the  diet.  It  should  not  be  our  object  to  tide 
over  a  few  months,  and  keep  a  baby  quiet  at  any 
hazard,  but  rather  to  lay  the  foundation  for  strong 
and  vigorous  childhood.  We  fail  to  accomplish 
this  if  we  use  a  food  lacking  in  any  of  its  essential 
elements,  though  the  child  may  for  a  few  months 
appear  to  digest  it  readily.  A  very  weak  food  is, 
of  course,  more  readily  digested  than  a  more 
nourishing  one,  and  this  is  the  secret  of  the  ready 
digestion  of  some  of  the  artificial  foods.  They  do 
not  contain  the  requisite  elements.  For  example, 
condensed  milk  is  usualh^  given  in  the  strength  of 
one  to  twelve.  But  in  this  proportion  the  food 
contains  but  one-eighth  the  amount  of  fat  and 
one-third  the  amount  of  caseine  found  in  normal 
breast  milk.  It  contains  so  much  sugar  that  the 
child  becomes  fat,  and  the  rickets  that  always 
follow  its  prolonged  use  is  covered  up.  Any 
material  increase  in  the  strength  of  the  condensed 
milk  mixture  so  increases  the  amount  of  sugar  that 
the  child  becomes  dyspeptic.  Close  observation 
of  thousands  and  thousands  of  cases  has  taught 
those  medical  men  whose  lives  are  given  to  the 
study  of  children  that  any  artificial  food  that  has 


286  HOW   TO    KEEP   WELL 

not  fresh  milk  as  its  basis  is  disappointing.  There 
are  apparent  exceptions  to  this  rule,  but  even  in 
these  exceptions  examination  reveals  evidence  o^ 
rickets,  if  not  more  serious  diseases.  It  is  unfor- 
tunate that  many  of  the  injurious  effects  of 
improper  feeding  are  not  immediately  apparent. 
Temporary  success  often  blinds  parents  to  undesir- 
able results  which  are  clearly  manifest  only  after 
weeks  or  months.  Were  these  results  immediately 
visible  there  would  be  much  less  injudicious 
feeding. 

It  seems  rational  to  take  the  mother's  milk  as 
the  standard  by  which  to  measure  the  artificial 
food,  when  such  food  must  be  used.  The  artificial 
food  should  contain  the  same  constituents  as  the 
standard,  and  they  should  be  present  in  about  the 
same  proportions.  If  we  apply  this  method  of 
measurement  to  the  various  artificial  foods  in  the 
market,  we  find  them  sadly  lacking.  A  few  of 
these  foods  have  in  recent  years  been  so  changed 
that  they  simply  become  additions  to  modified 
milk.  In  these,  however,  the  milk  is  rarely  given 
in  sufficient  strength.  The  infant's  natural  food 
is  an  animal  product,  consisting  of  fat  (cream), 
albuminous  matter  (caseine),  a  certain  form  of 
sugar  (sugar  of  milk),  and  mineral  salts.  The 
various    patent    foods    are    composed    largely    of 


THE    DIET   OF   CHILDREN  287 

vegetable  products.  They  are  one  and  all  lacking 
in  fat.  Their  albuminoid  matter  is  of  vegetable 
origin,  not  animal.  It  is  not  caseine.  Each  of  ■ 
these  elements  has  its  office  to  perform  in  the 
nutrition  of  the  child,  and  cannot  be  materially 
reduced  or  changed  in  character  without  detri- 
mental results.  The  fact  that  some  of  these  foods 
approach  the  standard  in  chemical  composition 
means  little.  The  chemist  only  determines  the 
amount  of  chemical  elements  present,  not  their 
properties  or  physical  form.  He  can  detect  no 
difference  between  a  diamond  and  a  piece  of  hard 
coal.  To  him,  they  are  simply  pieces  of  carbon. 
The  difference  between  these  foods  and  mother's 
milk,  although  the  chemist  finds  some  of  their 
elements  similar,  is  just  as  great  as  between  coal 
and  the  diamond.  Vegetable  oils  and  albuminoids 
are  very  different  from  animal  fats  and  albumin- 
oids, though  their  chemical  analysis  may  be 
similar. 

Cow's  milk  properly  modified  is  the  best  food 
for  an  infant,  because  on  that  food  he  will  develop 
into  the  sturdiest  child.  By  modified  milk  is 
simply  meant  milk  that  is  adapted  to  the  individual 
child.  Cow's  milk  is  not  the  same  in  its  propor- 
tions as  mother's  milk.  It  must  be  changed  or 
modified,  therefore,  in  the  strength  of  certain  of 


288  HOW   TO    KEEP   WELL 

its  ingredients.  There  is,  however,  no  one  strength 
that  is  adapted  to  all  children,  not  even  those  of 
the  same  age.  Successful  feeding  consists  in  adapt- 
ing the  milk  to  the  needs  and  digestive  power  of 
each  child.  No  one  formula,  therefore,  can  be 
given,  or  no  set  of  formulas.  Beginning  with  a 
weak  mixture,  it  should  be  slowly  increased  until 
it  m3ets  the  requirements  of  the  particular  child. 
T\e  four  essentials  necessary  to  successful  feeding 
are:  first,  the  use  of  pure,  fresh  cow's  milk;  second, 
adapting  it  to  the  digestive  capacity  of  the  child; 
third,  scrupulous  cleanliness  in  its  preparation  and 
all  the  details  of  handling;  fourth,  regularity  of 
feeding. 

A  word  of  advice  may  be  given  on  the  selection 
of  milk,  particularly  that  to  be  used  by  infants 
and  invalids.  One  of  the  drawbacks  to  its  use  is 
the  fact  that  it  may  become  contaminated,  as  may 
proprietary  foods  and  condensed  milk.  As 
cities  have  increased  in  size,  the  question  of  their 
milk  supply  has  become  of  grave  importance. 
Next  to  the  water  supply,  the  milk  supply  is  justly 
regarded  as  the  most  important  question  in  the 
hygienic  branch  of  municipal  affairs.  In  no 
department  of  public  hygiene  has  greater  advance- 
ment been  made  than  in  this.  The  improvement 
in  the  milk  supply  has  been  one  of  the  most  potent 


THE    DIET    OF    CHILDREN  289 

factors  at  work  in  the  reduction  of  child  mortality. 
At  first,  attention  was  chiefly  directed  to  sterilizing 
or  pasteurizing  milk  to  kill  the  germs.  This  was 
a  step  in  the  right  direction,  but  only  a  step.  We 
have  not  yet  reached  a  stage  of  perfection  which 
renders  it  safe  not  to  pasteurize  most  milk  used  by 
infants  in  hot  weather.  Another  step  has  been 
taken,  and  the  very  rational  course  has  been 
adopted,  of  attempting  to  keep  the  germs  out  of 
milk,  another  instance  of  the  modern  appreciation 
that  prevention  is  better  than  cure.  These  efforts 
have  been  directed  to  the  hygienic  improvement  of 
the  dairies,  the  exclusion  of  diseased  animals,  and 
improvements  in  methods  of  transporting  and 
delivering.  Really  clean  dairies  may  now  be  found 
all  over  the  country.  Cleanliness  in  every  detail 
in  the  management  of  the  buildings,  animals,  and 
employees,  with  abundance  of  sunlight  and  fresh 
air,  have  resulted  in  the  production  of  milk  so 
clean  that  it  will  keep  like  sterilized  milk.  Bacteri- 
ology has  shown  that  there  is  no  decomposition, 
fermenting,  or  souring  without  germs.  While  it 
has  not  been  possible,  and  probably  never  will  be 
feasible,  to  absolutely  exclude  certain  germs  from 
milk,  the  number  has  been  rendered  so  small  that 
if  the  milk  be  kept  at  a  low  temperature  it  will 
remain  wholesome  for  days.     Milk  from  American 


290  HOW   TO    KEEP   WELL 

dairies,  without  pasteurizing  or  the  addition  of 
chemicals,  was  sent  to  Paris  and  sold  on  the  grounds 
of  the  Exposition  during  the  summer  of  1900. 

The  importance  of  this  subject  of  clean  milk 
cannot  be  too  strongly  insisted  upon.  Clean  and 
wholesome  milk  can  be  obtained  in  every  large 
city  at  rates  but  little  more,  and  in  some  cases  the 
same,  as  those  charged  for  unwholesome  milk. 
Supply  follows  demand.  If  the  people  demand 
clean  milk,  they  can  have  it.  If  they  patronize 
only  those  dealers  who  supply  it,  every  dealer  will 
soon  be  forced  in  self-defense  to  produce  it.  The 
milk  known  in  many  places  as  "certified  milk"  is 
that  produced  under  the  supervision  of  a  commis- 
sion of  medical  men  and  scientific  experts.  This 
commission  has  no  financial  interest  in  the  dairy, 
their  only  interest  being  that  of  public-spirited 
citizens  endeavouring  to  improve  the  character  of 
one  of  the  most  important  staples  of  food.  The 
veterinary,  chemist,  and  bacteriologist  are  all 
responsible  to  this  commission. 

It  is  the  belief  of  competent  observers  that  no 
one  hygienic  measure  has  resulted  so  certainly  in 
the  reduction  of  mortality  rate  among  children  in 
New  York  City  as  the  improvement  in  the  milk 
supply.  What  is  true  in  New  York  is  equally  true 
in  other  large  cities.     Even  if  the  prepared  foods 


THE   DIET   OF   CHILDREN  291 

were  desirable,  they  are  too  expensive  for  use  by 
tlie  poor.  Until  recently  "grocery  milk"  was  the 
food  of  a  large  part  of  the  infant  population  of  the 
tenement  regions.  Of  the  various  efforts  made  to 
improve  this  food,  the  most  effective  has  been  the 
Straus  system  of  milk  depots.  By  this  great 
philanthropy  wholesome  milk  is  supplied  in  the 
tenement  regions  at  a  price  within  reach  of  the 
poorest.  It  is  given  out  in  separate  bottles,  each 
being  sufficient  for  a  single  feeding.  During  the 
first  five  years  of  the  existence  of  this  philanthropy 
more  than  2,000,000  bottles  of  milk  were  dis- 
tributed, as  many  as  7,000  having  been  given  out 
in  a  single  day.  During  the  summer  of  1902, 
976,040  bottles  were  given  out.  Several  dispen- 
saries have  adopted  similar  measures.  The  system 
has  been  educational  as  well  as  directly  beneficial, 
and  has  taught  the  mothers  as  nothing  else  could 
do  the  great  fact  that  the  summer  diseases  of 
children  are  preventable,  and  that  attention  to 
the  food  is  an  absolute  requirement  to  their  avoid- 
ance. These  facts,  together  with  a  marked 
improvement  in  the  general  milk  supply  of  the 
city,  are  among  the  most  potent  factors  in  improv- 
ing the  conditions  shown  by  the  mortality  records. 
They  teach  the  lesson,  which  the  well-to-do  should 
learn,  that  wholesome  food  is  the  chief  preventive 


292  '     HOW   TO    KEEP    WELL 

measure   against   the   most   prevalent   diseases   of 
early  childhood. 

The  importance  of  starting  the  diet  of  the  young 
infant  right  is  not  fully  appreciated.  The  foun- 
dation of  much  of  the  malnutrition,  indigestion, 
and  marasmus  seen  in  infants,  is  laid  during  the 
first  few  weeks  of  life.  Indigestion,  when  once 
established,  is  very  difficult  to  cure.  Its  effects 
often  continue  during  the  whole  of  the  first  year. 
An  attack  of  indigestion  must  be  regarded  as  a 
serious  misfortune;  the  younger  the  child,  the 
greater  the  misfortune.  A  single  careless  feeding 
may  cause  an  acute  indigestion  which  will  be  the 
starting  point  of  a  long  series  of  disturbances. 
The  error  is  quite  too  common  of  looking  upon 
the  body  as  a  machine,  any  derangement  of  which 
can  be  set  right  by  simply  removing  the  cause. 
The  human  body  is  not  a  lifeless  machine,  but 
a  combination  of  living  tissues.  Stopping  the 
original  cause  of  disturbance  does  not  usually  stop 
the  symptoms.  A  child  that  has  been  improperly 
fed  can  rarely  be  set  right  at  once  by  the  adminis- 
tration of  proper  food.  If  the  indigestion  is  due 
to  bacterial  action,  or  to  a  vegetable  ferment,  it 
will  probably  continue  for  a  certain  time  under 
the  most  favourable  feeding,  because  the  germ  or 
the  ferment  remains  to  act  upon  everything  that 


THE    DIET    OF    CHILDREN  293 

is  introduced  into  the  stomach.  An  intestinal 
catarrh,  when  once  begun,  is  very  slow  and  difficult 
of  cure,  and  will  prolong  the  indigestion. 

When  the  digestive  secretions  are  impaired  or 
undergo  any  decided  change,  they  do  not  at  once 
recover  themselves  or  adapt  themselves  to  changed 
conditions,  even  if  those  conditions  are  perfection 
itself.  The  nervous  system,  notably  that  portion 
which  presides  over  the  digestive  functions,  readily 
acquires  habits  and  peculiarities  of  action  which 
continue  after  the  causes  which  generated  them 
have  been  removed.  The  debility  and  anemia 
which  follow  in  the  train  of  improper  diet  are  felt 
by  the  digestive  organs  in  common  with  the  rest 
of  the  body,  and  impair  their  action  long  after  the 
cause  is  removed.  The  younger  the  child,  the  less 
is  its  resisting  power,  and  the  more  potent  do  these 
various  factors  become.  There  is  no  more  difficult 
task  than  the  remedying  of  an  impaired  digestion 
in  a  young  infant.  In  no  place  is  the  old  adage 
that  prevention  is  better  than  cure  more  true  than 
in  medicine ;  in  no  place  in  medicine  is  it  more  true 
than  in  the  management  of  early  infancy. 

No  detail  in  the  management  of  artificially  fed 
children  is  too  trivial  to  be  considered.  The 
neglect  of  some  of  these  details  will  often  more 
than  counterbalance  the  greatest  care  in  other 
directions.     It  is  impossible  in  this  place  to  con- 


294  HOW   TO    KEEP   WELL 

sider  all  these  matters,  it  not  being  within  the  plan 
of  this  work.  It  has  been  the  intention  rather  to 
point  out  the  essential  features  whose  observance 
has  resulted  in  the  saving  of  child  life.  The  sub- 
ject is  worthy  of  a  special  volume,  and  several 
reliable  books  are  available  in  which  the  various 
details  of  infant  feeding  and  management  are 
considered.*  The  great  thought  and  study  de- 
voted to  this  subject  during  the  past  two 
decades  are  bearing  fruit.  The  rate  of  death  dur- 
ing the  first  year  of  life  must  alwa3"s  be  excessive 
as  compared  with  later  years.  There  are  certain 
conditions  which  can  never  be  wholly  overcome. 
It  is  the  period  in  which  the  inexorable  law  of  the 
survival  of  the  fittest  is  most  rigorous  in  its  action. 
This  law  must  continue  to  act,  and  certain  of  the 
unfit  must  succumb.  A  considerable  part  of  the 
death  rate  in  the  past,  however,  has  been  made  up 
of  perfectly  healthy  children  whose  deaths  have 
become  unnecessary  in  the  light  of  present  knowl- 
edge. The  saving  of  these  valuable  lives  forms 
one  of  the  brightest  pages  of  modern  medicine. 

*  Among  the  best  of  these  books  on  the  management 
of  infancy  are  the  following:  "The  Care  and  Feeding  of 
Children,"  by  L.  Emmett  Holt,  M.  D.  (Appleton) ;  "The 
Baby,  His  Care  and  Feeding,"  by  Marianna  Wheeler, 
Superintendent  of  the  Babies'  Hospital  (Harpers) .  An 
excellent  Httle  book,  "The  Care  of  the  Baby,"  by  J.  P.  C. 
Griffith,  M.  D.  (Saunders);  "Talks  with  Young  Mothers," 
by  C.  G.  Kerley,  M.  D.  (Putnam) ;  "The  Century  Book  for 
Mothers,"  by  Yale  and  Pollak  (Century  Company). 


CHAPTER  XI 

Faulty  Nutrition  of  Children 

In  the  present  chapter  certain  conditions  of 
faulty  nutrition  in  children  are  considered.  They 
are  not  only  in  themselves  the  cause  of  illness  and 
death,  but  some  of  them  are  the  active  predispos- 
ing causes  of  other  and  more  serious  diseases. 
Although  classified  as  nutritional  disorders,  it 
must  be  said  that  there  are  some  who  regard 
rickets  and  scurvy  as  infectious  diseases,  but  this 
opinion  lacks  confirmation.  Malnutrition,  maras- 
mus, rickets,  scurvy,  and  anemia  form  a  group  of 
great  importance. 

Malnutrition  of  a  more  or  less  marked  type 
is  very  common  among  infants  and  children.  It 
varies  in  severity  from  slight  anemia  to  extreme 
marasmus.  It  occasionally  occurs  in  acute  forms. 
This  is  most  common  in  young  and  very  feeble 
infants,  but  it  may  result  from  improper  or  inade- 
quate diet  at  any  age.  More  commonly  it  is  slow 
and    progressive.       Malnutrition    is    a    condition, 

rather  than  an  actual  disease.     According  to  Holt, 

295 


296  HOAV   TO    KEEP    WELL 

in  each  hundred  well-marked  cases  about  twenty 
are  due  to  inherited  weakness  of  constitution,  about 
twenty  to  improper  or  insanitary  surroundings 
and  improper  methods  of  care,  and  about  sixty  to 
improper  methods  of  feeding.  While  inheritance 
seems  to  be  the  only  factor  in  some  cases,  it  is  a 
contributing  factor  in  many  others.  The  children 
of  tuberculous,  alcoholic,  and  very  feeble  parents 
are  prone  to  malnutrition.  The  same  is  true  when 
one  or  both  parents  are  high  strung  and  unstable 
in  nervous  temperament,  the  so-called  nervous 
people.  Not  only  are  the  children  of  erratic  and 
nervous  mothers  prone  to  be  delicate,  but  they  are 
apt  to  receive  injudicious  care,  with  overindulgence 
in  one  direction  and  overseverity  in  another. 

The  second  active  cause  of  malnutrition  is 
improper  hygienic  care  and  unsanitary  surround- 
ings. It  is,  therefore,  common  in  tenement  regions, 
and  accounts  for  the  high  mortality  of  the  chil- 
dren of  those  localities  when  attacked  by  acute 
disease.  Similar  causes,  however,  are  sometimes 
active  in  well-to-do  families.  Children  who  are 
kept  in  close  rooms,  without  proper  exercise  in  the 
open  air,  are  very  prone  to  be  delicate,  and  easily 
pass  into  a  stage  of  malnutrition.  Overcautious 
mothers  frequently  cause  the  very  conditions  they 
are  striving  to  avoid. 


FAULTY  NUTRITION  OF  CHILDREN  297 

The    most    potent     cause     of    malnutrition    is 
improper  feeding.     The  child  may  receive  inade- 
quate nourishment  and  become  anemic  and    thin 
simply  from  lack  of  food.     In  a  far  greater  number 
of    cases,    however,    the    opposite    error    is    made. 
Many  more  children    are    overfed    than    underfed. 
If  a  child  receives  more  food  than  it  can  properly 
digest,  but  still  a  quantit}^  short  of  causing  acute 
indigestion,  the  symptoms  to  the  ordinary  observer 
are  frequently  those  of  insufficient  feeding.     The 
surplus   food,   instead  of  being  properly   digested, 
ferments,  and  causes  restlessness    and  discomfort, 
and    other    symptoms    which    are    attributed    to 
hunger.     Pernicious  products  are  formed  by  such 
fermentation  which  are  absorbed  and  cause  loss  of 
flesh.     The  same  results  may  follow  the  giving  of 
improper  food.     Much  of  the  malnutrition  in  young 
infants   results   from   errors   in   starting   the   diet. 
The  digestive  functions,  being  once  deranged,  are 
very  slow  to  return  to  their  normal  condition,  and 
the     general     nutrition     suffers.     Importance     of 
starting  the  child's  diet  right  is  considered  in  the 
preceding   chapter,   and  is  again  referred  to  only  to 
enforce  its  importance. 

An  attack  of  acute  illness  is  frequently  the  start- 
ing point  of  malnutrition.  The  depressed  condi- 
tion produced  by  the  illness  is  felt  by  the  digestive 


298  HOW    TO    KEEP   WELL 

organs  in  common  with  all  the  other  organs  of  the 
body.  The  child  is  not  able  to  digest  sufificient 
food  to  replace  the  waste  produced  by  the  illness, 
and  gradually  falls  into  a  state  of  impaired  nutri- 
tion. This  does  not  necessarily  follow  acute 
disease,  but  in  feeble  children  and  in  those  in  whom 
predisposing  causes  are  present,  it  is  not  an  in- 
frequent result.  In  older  children  it  is  one  of 
the  most  common  causes  of  impaired  nutrition. 
The  prolonged  and  wasting  diseases  are  those 
which  are  most  often  followed  by  malnutri- 
tion, but  occasionally  short  and  acute  illness  may 
cause  it.  The  diarrheal  diseases  are  frequently 
followed  by  weeks  and  even  months  of  physical 
depression,  in  which  the  feeding  is  a  difficult  and 
distressing  task.  A  warning  should  be  given  to 
parents  against  the  danger  of  assuming  that  in 
every  case  of  impaired  nutrition  only  the  condition 
of  simple  malnutrition  is  present.  It  is  the  first 
symptom  of  several  of  the  wasting  diseases,  and 
medical  advice  should  be  sought  lest  this  error 
be  made. 

Many  of  these  children  of  feeble  digestion,  the 
result  either  of  inheritance  or  inherent  weakness, 
are  sources  of  great  care  and  anxiety,  for  their 
feeding  is  always  difficult.  As  soon  as  the  strength 
of  the  food  is  increased  to  the  point  where  the  child 


FAULTY  NUTRITION  OF  CHILDREN  299 

will  gain  adequately  in  weight,  the  digestion  fails 
and  the  food  must  be  reduced.  So  there  is  a  con- 
stant struggle  between  insufficient  nourishment 
upon  the  one  hand  and  indigestion  upon  the  other. 
In  either  case,  more  or  less  malnutrition  is  the 
result.  The  difficulties  of  the  mother  in  such  cases 
are  usually  not  confined  to  her  trials  with  the  child. 
The  advice  of  well-meaning  friends  is  too  often 
added  to  her  other  troubles.  Healthy  and  vigor- 
ous children,  whose  digestion  causes  little  trouble 
under  any  method  of  feeding,  are  held  up  to  her  as 
models.  The  advice  to  give  the  child  more  food  is 
the  one  most  commonly  offered.  The  feebleness 
of  digestion  is  attributed  to  her  overcautiousness. 
She  finally  yields  in  an  evil  moment,  and  her 
troubles  are  increased  by  resulting  indigestion  and 
greater  malnutrition.  The  officious  friend  who 
made  the  trouble  will  be  none  the  less  ready  to 
offer  other  advice  at  her  next  visit.  The  advice- 
giving  female  never  learns  by  experience.  Her 
knowledge  comes  by  intuition,  and  is  extensive, 
because  she  knows  so  many  things  that  are  not  so. 
The  only  safe  course  to  pursue  with  these  frail 
children  is  cautiousness  and  eternal  vigilance. 
While  it  is  true  that  feebleness  of  digestion  con- 
tinues through  childhood  in  some  children,  and 
even  through  adult  life,  there  are  many  others  in 


300  HOW   TO   KEEP   WELL 

whom  it  diminishes  or  disappears  during  the 
second  or  third  year.  Many  infants  who  have 
weak  digestion  and  are  difficult  to  feed  during  the 
first  year  develop  into  hardy  children. 

Marasmus  is  an  extreme  form  of  malnutrition, 
and  is  not  common  in  well-to-do  private  practice. 
The  occasional  cases  seen  under  such  circumstances 
usually  follow  some  long-continued  and  wasting 
disease,  particularly  prolonged  attacks  of  summer 
diarrhea.  Except  when  resulting  from  sucJi 
conditions,  it  is  caused  chiefly  by  improper  food 
and  unsanitary  surroundings.  When  this  extreme 
condition  of  malnutrition  is  reached  the  outlook  is 
very  discouraging.  It  is  particularly  so  under 
eight  months.  The  causes  are  dietetic  and 
hygienic,  and  must  be  prevented  and  cured  by 
dietetic  and  hygienic  measures. 

Rickets,  or  rachitis,  is  a  chronic  disease  of  nutri- 
tion which  is  rapidly  increasing  in  frequency  in 
this  country.  Its  most  characteristic  symptoms 
are  due  to  softening  of  the  bones  and  enlargement 
of  the  ends  of  the  long  bones.  The  disease,  how- 
ever, is  not  limited  to  the  bones,  but  affects  all  the 
tissues  of  the  body,  particularly  the  muscles  and 
some  of  the  abdominal  organs.      While  it  is  rarely 


FAULTY  NUTRITION  OF  CHILDREN  301 

the  direct  cause  of  death,  it  is  a  condition  of 
impaired  nutrition  which  renders  children  particu- 
larly susceptible  to  acute  diseases,  and  adds 
greatly  to  their  danger  when  they  occur.  The 
rachitic  child  has  not  the  stamina  and  ability  to 
resist  illness  which  the  healthy  child  possesses. 
Rickets  is  most  common  between  six  months  and 
three  years,  but  its  results  are  frequently  apparent 
throughout  childhood,  and  even  into  adult  life. 

The  most  characteristic  symptoms  of  the  early 
stages  and  of  mild  cases  are  sweating  of  the  head 
and  neck  while  the  rest  of  the  body  remains  dry; 
restlessness  at  night ;  constipation ;  delayed  denti- 
tion; slight  enlargement  at  the  ends  of  the  bones, 
particularly^  at  the  wrists  and  ankles ;  and  what  is 
known  as  the  chest  rosary.  This  latter  consists  of 
a  row  of  little  enlargements  on  each  side  of  the 
chest  at  the  ends  of  the  bony  portions  of  the  ribs. 
Either  of  the  first  four  of  these  symptoms  may  be 
present  alone  without  indicating  rickets.  The 
combination  of  several  of  them  is  indicative  of  that 
condition.  In  the  severer  cases,  deformities  more 
or  less  marked  are  the  result  of  the  softened  bones. 
Pigeon  breast,  knock-knee  or  bowlegs,  and  enlarge- 
ment of  the  head,  are  the  most  common  deformi- 
ties. In  the  more  extreme  cases  other  deformities 
occur,   but   they   are   rare   among   the   well-to-do. 


302  HOW   TO    KEEP   WELL 

In  the  milder  cases  the  deformities  improve  some- 
what as  the  child  grows  older  and  stronger.  The 
more  marked  deformities  can  only  be  relieved  by 
surgical  operation. 

Rickets  has  enormously  increased  in  this 
country,  having  kept  pace  with  the  growth  of  the 
cities  and  the  increase  in  foreign  population.  It 
is  particularly  common  among  the  Italians  and 
Negroes  of  the  North.  It  is  a  disease  which  com- 
monly follows  the  transplanting  of  a  southern  race 
"into  a  colder  climate.  It  is  by  no  means  limited 
to  these  people,  however,  but  is  found  in  every 
grade  of  the  social  scale,  and  is  becoming  more 
common  in  villages  as  well  as  large  cities.  It  is 
so  common  in  the  cities  of  England  that  on  the 
continent  of  Europe  it  is  universally  known  as  the 
English  disease. 

Rickets  is  essentially  dietetic  in  its  nature,  but 
bad  hygiene  is  an  important  element  in  its  causa- 
tion. It  is  a  complex  condition,  and  not  due  to  a 
single  cause.  The  idea,  held  for  many  years,  that 
it  was  due  to  a  lack  of  lime,  is  now  known  to  be 
incorrect.  Owing  to  the  softness  of  the  bones, 
this  was  a  natural  conclusion  to  have  reached 
before  pathology  was  as  well  understood  as  it  is  at 
present.  Tlie  diet  which  will  be  most  certainly 
followed  l.)y  rickets  is  one  that  is  deficient  in  fat. 


FAULTY  NUTRITION  OP  CHILDREN  303 

If  deficient  in  albuminoids,  also,  the  certainty  of 
its  occurrence  is  increased.  If  to  this  is  added  an 
excess  of  sugar  or  starch,  we  have  the  diet  par 
excellence  for  the  production  of  rickets.  Such  a 
diet  we  have  in  condensed  milk  and  certain  of  the 
proprietary  foods.  Their  prolonged  use  is  always 
followed  by  rickets.  The  excess  of  sugar  in  these 
foods  produces  fat.  Hence,  we  often  see  in  chil- 
dren thus  fed  striking  examples  of  "fat  rickets." 
The  fat  covers  a  multitude  of  rachitic  sins  from 
the  eyes  of  the  inexperienced.  Such  children 
often  make  very  pretty  pictures,  of  the  kind 
adapted  to  the  adorning  of  advertising  pages. 
Rachitic  children  usually  fulfil  Kerley's  descrip- 
tion of  them  as  an  "ill-conditioned  class  of  children, 
with  their  starved  muscular  and  nervous  systems 
and  catarrhal  tendencies,  who  fall  an  easy  prey  to 
broncho-pneumonia  in  the  winter,  to  the  gastro- 
intestinal diseases  in  the  summer,  and  to  the  infec- 
tious diseases  during  the  entire  year."  As  regards 
really  well -nourished  children  who  have  been 
reared  exclusively  on  condensed  milk,  the  same 
author  aptly  remarks  that  the  doctor  hears  of 
more  than  he  sees. 

Of  the  unsanitary  conditions  tending  to  produce 
rickets,  lack  of  sunlight  and  air  is  the  most  potent. 
It  is  the  children  in  the  tenement  regions,  and  those 


304  HOW   TO    KEEP   WELL 

in  the  close  and  unventilated  nurseries  in  the  smart 
regions  of  large  cities,  who  suffer  most.  If  to  these 
conditions  is  added  injudicious  diet,  rickets  is 
certain  to  follow.  Those  who  might  tolerate  lesser 
errors  in  diet  in  good  sanitary  surroundings  may 
become  rachitic  in  unwholesome  ones.  Rickets 
is  so  rare  in  breast-fed  babies  as  to  be  a  curiosity. 
The  prevention  of  rickets  is  dietetic  and  hygienic, 
as  indicated  by  a  study  of  its  causation.  The  first 
involves  a  knowledge  of  the  modern  science  of 
infant  feeding.  The  general  outline  of  prevention 
is  as  follows :  give  a  food  which  contains  an  ade- 
quate proportion  of  fat;  exclude  starchy  foods 
from  the  diet  of  infants  under  six  or  eight  months, 
and  give  them  in  moderation  after  that  age;  give 
the  child  an  abundance  of  sunlight  and  air,  and  keep 
him  in  the  best  hygienic  surroundings  possible.  In 
addition  to  this,  clothing,  bathing,  and  other 
details  of  hygienic  care  should  not  be  neglected. 
It  should  be  understood,  however,  that  rickets 
may  develop  in  the  best  of  surroundings  if  the  diet 
is  faulty.  A  warning  may  be  given  against  going 
to  the  other  extreme  in  the  diet  and  giving  more 
fat  than  the  child  can  digest.  This  will  produce 
troubles  of  its  own.  The  proper  course  is  not 
toward  either  extreme.  When  it  is  possible,  city 
children,  who  are  the  most  liable  to  suffer  from 


FAULTY  NUTRITION  OF  CHILDREN  305 

rickets,  should  be  sent  into  the  country  during 
the  warm  weather.  Sea  air  is  particularly  bene- 
ficial when  there  is  a  rachitic  tendency.  Rachitic 
children  must  be  managed  with  particular  caution, 
for  they  are  readily  disturbed  by  causes  that  a 
normal  child  would  not  feel.  Great  caution  must 
be  observed  in  making  sudden  and  extreme 
changes  in  diet  and  clothing. 

An  important  agent  in  the  prevention  of  rickets, 
as  well  as  in  treatment,  is  cod-liver  oil.  It  supplies 
fat  in  a  form  which  seems  particularly  valuable 
to  the  children  who  show  this  tendency.  It  is  a 
wise  plan  to  give  it  to  delicate  children  in  small 
doses  twice  or  perhaps  three  times  a  day  for  one 
or  two  weeks  in  each  month  during  the  cold 
weather.  In  such  cases  it  is  to  be  regarded  as  a 
food  rather  than  a  medicine. 

More  space  has  been  given  to  this  subject  than 
to  many  diseases  with  a  higher  death  rate,  for  the 
reason  that  few  other  conditions  so  predispose  to 
illness  as  does  this.  The  doctor  is  apt  to  find  that 
those  children  who  suffer  from  one  illness  after 
another,  and  are  said  to  catch  everything  that  comes 
along,  are  either  rachitic  or  have  been  so  in  their 
early  childhood.  The  prevention  of  rickets  means 
the  prevention  of  many  other  ills,  and  the  saving 
of  a  child  from  many  dangers. 


3o6  HOW   TO    KEEP    WELL 

Scurvy. — When  the  statement  was  made,  about 
ten  years  ago,  that  scurvy  was  becoming  common 
among  infants,  it  was  received  with  incredulity 
by  medical  men.  The  unfortunate  truth,  however, 
soon  became  too  apparent  to  be  ignored.  Eight 
years  ago  I  found  thirty-six  authentic  cases 
reported  in  American  medical  literature.  Many 
times  this  number  had  undoubtedly  occurred  and 
had  not  been  reported.  Four  years  ago  a  com- 
mittee of  the  American  Pediatric  Society  collected 
379  cases  in  which  full  and  satisfactory  histories 
could  be  obtained.  They  occurred  in  the  practice 
of  138  physicians.  When  such  a  number  of  cases 
have  been  reported  in  full,  it  is  evident  that  the 
disease  is  not  a  rarity  or  a  curiosity. 

A  peculiar  feature  of  the  disease  is  the  fact  that 
it  is  rarely  found  in  the  tenement  regions  or  among 
the  poor,  but  occurs  in  the  homes  of  the  wealthy 
and  among  the  children  who  are  cared  for  with  the 
utmost  solicitude.  Whether  it  occurs  in  infants 
or  adults,  it  is  due  to  a  lack  of  fresh  food.  It  was 
common  years  ago  among  sailors,  arctic  explorers, 
and  soldiers,  when  salt  food  was  largely  used, 
and  modern  methods  of  food  preservation  were 
unknown.  Since  the  nature  of  the  food  has 
changed,  and  lime  juice  and  lemons  are  taken  to 
sea,    the   disease   has   disappeared.     It   has   again 


FAULTY  NUTRITION  OF  CHILDREN  307 

appeared,  because  the  same  principle  of  diet  has 
again  been  brought  into  vogue.  Condensed  milk, 
and  proprietary  foods  designed  to  be  used  without 
the  addition  of  fresh  milk,  came  largely  into  use  in 
the  feeding  of  children.  The  fresh  element  of  food 
was  lacking,  and  the  children  became  scorbutic. 
Proprietary  foods  are  too  expensive  for  use  by  the 
poor.  Their  children,  therefore,  escape  one  evil. 
In  families  where  there  are  several  children  to  be 
looked  after  by  a  mother  who  has  many  other 
cares,  the  diet  is  not  rigidly  watched.  The 
neglected  child  who  eats  everything  at  the  table 
may  become  rachitic  or  marasmic,  but  he  obtains 
enough  fresh  food  to  keep  him  from  scurvy.  Even 
fresh  milk  diluted  to  a  very  weak  mixture  is  not 
sufficient  for  protection.  The  committee  report 
already  referred  to  places  the  use  of  the  proprietary 
foods  and  condensed  milk  as  the  first  cause  of 
scurvy,  in  the  point  of  numbers  they  produce. 
The  same  was  true  of  those  cases  which  I  first 
reported. 

Scurvy  is  a  very  fatal  disease  when,  not  recog- 
nized in  time  and  properly  treated.  Of  the  397 
cases  referred  to,  29  died.  It  is  easily  mistaken 
for  rheumatism,  rickets,  acute  disease  of  the  bones, 
and  paralysis.  The  prominent  symptoms  are 
painful  swelling  of  the  legs  just  above  the  knee, 


3o8  HOW    TO    KEEP   WELL 

and  occasional  swelling  of  the  arms,  spongy  and 
bleeding  gums,  and  frequently  hemorrhages  under 
the  skin  or  from  cavities  of  the  body.  The  swell- 
ings are  intensely  painful,  and  the  child  screams 
at  the  slightest  touch.  Anemia  and  malnutrition 
are  usually  present,  and  there  is  frequently  a  pecu- 
liar form  of  paralysis  due  to  the  intensity  of  the 
pain  on  motion.  This  false  paralysis  disappears 
as  soon  as  the  other  symptoms  subside.  The  dis- 
ease is  most  common  about  the  end  of  the  first 
year,  but  may  occur  at  any  age  if  an  absolutely 
strict  diet  of  cooked  food  be  given.  I  saw  several 
cases  in  the  idiot  asylum  due  to  the  use  of  gruel 
which  some  of  the  patients  insisted  upon  taking 
to  the  exclusion  of  all  other  diet.  Prevention 
consists  solely  in  giving  a  rational  food  whose  basis, 
for  infants,  is  fresh  cow's  milk.  Treatment  is 
simple,  but  the  results  are  very  brilliant.  Medicine 
is  absolutely  useless.  The  disease  is  rapidly  cured 
by  the  use  of  fresh  milk  in  strength  adapted  to  the 
child's  digestion,  with  the  addition  of  small 
amounts  of  orange  juice. 

Scrofula  is  a  term  no  longer  used  by  medical 
men,  because  the  diseases  to  which  it  was  formerly 
applied  are  now  known  to  be  tubercular  in  their 
nature.     A  special  name  is  not  required,  therefore. 


FAULTY  NUTRITION  OF  CHILDREN  309 

The  conditions  long  known  as  scrofulous  are  simply- 
localized  tuberculosis.  The  most  common  of  these 
is  tuberculous  adenitis,  or  inflammation  of  the 
lymphatic  glands,  particularly  those  of  the  neck. 
The  tubercle  bacilli  enter  through  the  tonsils  or 
the  mucous  membrane  of  the  throat  and  nose,  and 
are  taken  by  the  lymphatic  vessels  to  the  lymphatic 
glands.  Here  they  cause  a  chronic  type  of  inflam- 
mation which  often  results  in  suppuration,  which 
is  also  very  chronic  in  character.  If  neglected, 
the  pus  finally  discharges  spontaneously,  leaving 
ragged,  chronic  ulcers,  the  so-called  scrofula  sores. 
When  these  have  finally  healed,  large,  irregular 
scars  are  left  behind  and  are  permanent.  The 
whole  duration  of  the  disease  is  usually  about  three 
and  a  half  years,  but  may  be  much  longer.  The 
discharge  from  these  sores  is  often  swarming  with 
tubercle  bacilli,  and  is  as  dangerous  as  is  the  expec- 
toration of  consumptives,  and  should  be  disposed 
of  with  much  care. 

When  the  glands  have  become  enlarged  they  may 
frequently  be  reduced  by  active  constitutional 
treatment  or  change  of  climate.  If  they  persist, 
or  grow  larger  after  several  months,  removal  by 
surgical  methods  is  advisable.  A  small,  clean  scar 
is  thus  left  instead  of  an  unsightly  one;  the  disease 
is  shortened,  and  the  long  and  exhausting  suppura- 


3IO  HOW    TO    KEEP   WELL 

tion  is  avoided;  the  danger  of  general  infection  of 
the  patient  is  removed,  as  well  as  danger  to  others. 
The  term  "scrofulous,"  or  "strumous  tendency," 
is  still  frequently  used.  A  predisposition  to  some 
particular  form  of  disease  is  seen  in  many  people. 
This  the  doctors  call  a  diathesis.  The  most  com- 
mon diatheses  are  the  rheumatic,  the  uric  acid,  the 
gouty,  and  the  strumous.  It  should  be  understood 
that  there  is  no  such  disease  as  scrofula,  but  only 
a  tendency  or  diathesis  which  predisposes  to  certain 
disorders,  and  modifies  every  disease  from  which 
the  individual  may  suffer.  Much  was  said  by  the 
older  writers  upon  the  physiognomy  of  scrofulous 
children,  two  types  being  commonly  described: 
the  one  fair  and  delicate,  with  thin  skin  and  soft 
hair;  the  other  dark  and  gross,  with  thick,  muddy 
skin  and  coarse  hair.  Wliile  there  is  some  basis 
of  truth  for  this  classification,  the  minute  details 
and  long-drawn-out  descriptions  were  mostly 
evolved  from  the  imagination.  There  was  a  time 
when  almost  every  disease  of  childhood  was 
attributed  to  scrofula,  particularly  rickets  and 
the  various  forms  of  malnutrition.  As  recovery 
from  many  of  these  diseases  is  common,  it  is  not 
strange  that  the  "King's  Evil"  often  improved 
after  the  child  was  touched  by  the  monarch. 
King  Charles  IL  touched,  in  twenty  years,  92,107 


FAULTY  NUTRITION  OF  CHILDREN  311 

persons.  Doctor  Johnson,  when  a  child,  was 
touched  by  Queen  Anne,  but,  according  to  the 
description  given  by  Boswell,  he  showed  a 
strong  scrofulous  tendency  to  the  end  of  his 
days. 

Two  conditions  are  particularly  common  in 
children  of  the  scrofulous  tendency — enlargement 
of  the  lymphatic  glands,  which  has  already  been 
referred  to,  and  a  tendency  to  catarrh  of  the 
mucous  membranes.  Certain  diseases  of  the  joints 
and  skin  are  also  rather  common  to  children 
showing  this  tendency.  The  tendency  to  catarrh 
renders  a  child  particularly  liable  to  nasal  catarrh, 
adenoid  growths,  enlarged  tonsils,  discharges  from 
the  ears,  inflamed  eyes,  and  bronchial  colds. 
Scratches  and  injuries  suppurate  easily,  and  sores 
heal  slowly.  A  vaccination  on  the  arm  of  a  child 
of  this  tendency  is  prone  to  suppurate,  and  run  a 
longer  course  than  the  normal,  but  it  does  not 
produce  "scrofula."  The  scrofulous  tendency 
was  there,  and  the  irregular  course  of  the  vaccina- 
tion was  but  one  of  its  manifestations.  Such 
children  lack  the  power  to  resist  bacteria  which  the 
normal  organism  possesses.  Hence  their  wounds 
become  infected  more  easily  than  those  of  average 
children  do,  and  they  contract  contagious  diseases 
more   readily.     The   most   serious    feature   of   the 


312  HOW   TO    KEEP   WELL 

strenuous  diathesis  is  the  strong  tendency  it 
engenders  to  tuberculosis.  Not  only  is  localized 
tuberculosis  of  the  lymph  glands  very  common, 
but  general  infection  is  much  more  liable  to  occur 
than  it  is  in  other  children. 

The  strumous  diathesis  is  usually  congenital, 
and  often  hereditary.  It  may,  however,  be 
acquired.  The  conditions  which  produce  it  are 
life  in  ill-ventilated  and  overcrowded  habita- 
tions, absence  of  sunlight,  unsuitable  food  and 
clothing — in  fact,  the  conditions  which  are  associ- 
ated with  poverty  and  squalor.  It  has  been 
well  called  la  scrofula  a  miser ia.  The  prevention 
of  hereditary  scrofulous  tendency  consists  in  the 
proper  management  of  the  ancestors  for  two 
or  three  generations  back,  in  precluding  the  mar- 
riage of  two  persons  who  each  show  the  tendency, 
and  in  preventing  consanguineous  marriages.  The 
tendency,  when  manifest  in  a  child,  may  be  - 
largely  and  often  entirely  overcome  by  suitable 
and  nourisliing  food,  life  in  the  open  air,  judicious 
clotliing,  and  the  observance  of  the  numerous 
details  which  constitute  hygienic  living.  Among 
the  foods  especially  useful  in  such  cases  is  cod-liver 
oil,  which  may  usually  be  given  to  great  advantage 
at  intervals  during  the  cooler  portions  of  the  year. 
It  is  fortunate  if  such  a  child  can  be  under  the 


FAULTY  NUTRITION  OF  CHILDREN  313 

observation  of  a  judicious  physician,  by  whom 
he  may  be  seen  at  intervals  of  a  few  months  during 
childhood.  He  may  thus  be  saved  from  many 
pitfalls,  and  the  tendency  to  illness  may  be  largely 
eradicated. 

There  are  other  diseases  of  nutrition,  and  special 
forms  of  anemia,  but  the  conditions  described  in 
this  chapter  are  the  most  frequent  forms  of  per- 
verted nutrition  in  early  life,  and  are  the  ones 
which  are  the  most  potent  as  predisposing  causes 
of  the  various  illnesses  which  occur  among  children. 
Their  prevention  will  do  much  to  prevent  disease 
and  death  during  the  period  of  childhood  and  early 
youth.  The  infectious  disorders  of  infants  and 
children  are  considered  in  the  chapter  on  the 
special  infectious  diseases. 


CHAPTER  XII 
Heredity 

Heredity  is  a  subject  upon  which  many  errone- 
ous views  are  held.  Many  things  are  attributed 
to  it  for  which  it  is  not  in  the  shghtest  degree 
responsible.  It  is  a  difficult  subject  to  make  clear 
to  the  average  reader,  for  it  involves  complex 
questions  of  biology.  It  is,  moreover,  concerned 
with  certain  matters  difficult  to  discuss  in  a  popular 
treatise.  No  attempt  will  be  made,  therefore, 
in  the  present  chapter,  to  present  the  subject  in  a 
systematic  or  exhaustive  manner.  Certain  points 
only  will  be  touched  upon  which  are  of  popular 
interest,  and  concerning  which  there  is  a  misunder- 
standing. 

The  first  point  upon  which  error  is  made  is  the 
confusing  the  two  fundamental  terms,  hereditary 
and  congenital.  This  error  is  due  to  the  common 
mistake  of  regarding  the  individual  as  beginning 
his  existence  at  the  moment  of  birth,  and  not  until 
then.  Everything  occurring  before  that  moment  is 
popularly  grouped  as  hereditary.     What  a  person 

314 


HEREDITY  315 

is  born  with  is  congenital;  it  may  be  hereditary 
or  it  may  not.  Birth  is  simply  a  date  at  which 
a  change  occurs  in  the  mode  of  existence,  not  in  the 
individual.  "That  alone  is  inherited  which  is 
the  property  of  the  individual  at  the  moment  he 
becomes  an  individual,  which  is  the  property  of 
the  germ  plasms  from  which  he  originates."  An 
accident  before  birtli  may  cause  a  deformity, 
but  it  is  not  hereditary;  it  is  congenital.  A  dis- 
ease may  be  transmitted  to  the  child  before  birth. 
It  comes  to  it,  however,  like  the  accident,  and  is 
also  congenital,  not  hereditary. 

It  must  be  said,  however,  that  to  the  average 
individual  this  distinction  seems  unnecessary. 
If  he  has  been  born  with  some  defect,  it  makes 
little  difference  to  him  whether  it  be  called  heredi- 
tary or  congenital.  He  may  have  the  satisfaction 
of  knowing,  however,  that  if  it  is  not  hereditary  he 
is  not  in  as  much  danger  of  involving  his  descend- 
ants in  the  same  misfortune.  It  is  still  as  true 
as  it  has  ever  been  that  the  iniquities  of  the  fathers 
are  often  visited  upon  the  children  and  the  chil- 
dren's children,  not  always  as  the  same  disease, 
but  as  a  defective  body  or  brain  or  an  enfeebled 
constitution.  "The  fathers  have  eaten  sour  grapes, 
and  the  children's  teeth  are  set  on  edge."  One 
cannot  sin  against  his  own  body  or  soul  without 


3i6  HOW    TO    KEEP   AVELL 

the  danger  that  his  children  will  suffer  for  it  in 
the  future. 

Another  point  much  misunderstood,  even  by 
medical  men,  is  the  fact  that  conditions  acquired 
by  the  parents  are  not  transmitted  by  heredity. 
The  law  of  Galton,  enunciated  more  than  twenty- 
five  years  ago,  has  never  been  disproved: 
"Acquired  modifications  are  rarely,  if  at  all, 
inherited  in  the  correct  sense  of  the  term."  For 
example,  polydactylism,  or  redundance  of  the 
fingers,  is  very  hereditary,  and  is  seen  in  families 
generation  after  generation;  but  the  child  of  a 
father  who  has  had  his  arm  amputated  is  not 
born  with  one  arm.  The  same  is  true  of 
diseases.  There  are  several  that  are  congenital, 
probably  none  that  are  hereditary. 

Another  term  which  requires  definition  is 
degeneracy.  It  is  often  confused  with  heredity. 
Degeneracy  is  at  present  a  popular  fad  both  within 
and  without  the  medical  profession,  and  has  been 
made  to  cover  a  multitude  of  conditions  to  which 
it  cannot  with  any  scientific  propriety  be  applied. 
The  jaundiced  mind  of  Nordau  sees  only  a  jaun- 
diced and  degenerate  world,  and  has  attempted 
to  throw  the  stigma  of  degeneracy  over  many 
conditions  due  to  totally  different  causes.  A 
brief  review  of  the  meaning  of  the  two  terms  may, 


HEREDITY  317 

therefore,  be  profitable.  Heredity  is  "the  inheri- 
tance of  certain  qualities  or  tendencies."  It  has 
still  further  been  defined  as  "the  tendency  mani- 
fested by  an  organism  to  develop  in  the  likeness 
of  its  progenitors."  Degeneracy,  on  the  other 
hand,  is  "the  absence  or  loss  of  that  degree  of 
development  or  energy  seen  in  the  ancestry  of  the 
organism."  Maudsley  defines  degeneration  as 
follows:  "It  is  now  used  exclusively  to  denote 
a  change  from  a  higher  to  a  lower  kind;  it  is  a 
process  of  dissolution,  the  opposite  of  the  process  of 
involution.'" 

It  is  clear,  therefore,  that  heredity  and  degen- 
eracy are  two  quite  different  conditions.  The 
one  is  a  tendency  to  develop  the  type  of  the  ances- 
tor, the  other  is  a  tendency  to  develop  a  lower 
type  than  that  of  the  ancestor.  Heredity  is 
always  due  to  inheritance;  degeneracy  may  be  due 
to  inheritance  or  acquisition. 

There  is  an  important  practical  deduction  to  be 
drawn  from  this.  Hereditary  tendencies,  even  if 
they  are  not  good,  ma}^  be  modified  or  improved 
by  training  and  judicious  management.  Mental 
capacity  may  be  encouraged  and  drawn  out  by 
education.  A  tendency  to  disease  may  be 
eradicated,  or  the  disease  may  be  cured,  but 
there    is    no    cure    for  that    which   is  not  disease, 


31 8  HOW   TO    KEEP    WELL 

but  defect.  Much  thought  has  been  given  in 
recent  years  to  the  training  of  defective  and 
backward  children.  Much  may  be  accompHshed 
by  skilled  and  judicious  training  in  the  milder 
cases,  and  something  in  the  graver  ones.  What 
capacity  there  is  may  be  developed  and  drawn 
out,  often  in  a  surprising  manner,  but  if  there  is 
actual  deficiency  the  limit  must  be  reached  sooner 
or  later.  There  is  no  human  skill  that  can  furnish 
deficient  brain  or  body  tissue.  The  old  adage  is 
here  particularly  true:  "AVhat  the  cradle  rocks 
the  spade  will  cover."  But  beware  of  hasty 
judgments  in  children.  Some  are  precocious, 
and  ripen  early;  others  mature  late,  like  winter 
fruit.  Some  of  these  backward  and  undemon- 
strative children  are  simply  slow  in  development, 
but  finally  reach  a  high  degree  of  maturity  and  have 
great  staying  powers.  Do  not  jump  to  conclusions, 
but  give  every  child  a  fair  chance. 

There  are  certain  factors  of  heredity  to  which 
I  wish  to  call  particular  attention.  They  are  four 
in  number: 

I.  There  are  elements  of  good  heredity  which 
frequently  neutralize  those  of  bad  heredity. 

There  seems  to  be  a  strong  tendency  to  forget 
that  there  is  such  a  thing  as  good  heredity.  .  It  is 
an  erroneous  but  very  common  belief  that  certain 


HEREDITY  319 

diseases  are  always  repeated  unniitigated  from 
generation  to  generation.  The  mere  expression, 
"hereditary  tendency,"  seems  to  suggest  to  most 
minds  tuberculosis,  scrofula,  rheumatism,  or  gout. 
We  now  recognize  the  fact  that  diseases  are  not 
directly  inherited,  but  rather  some  tissue  peculi- 
arity which  renders  the  individual  peculiarity 
susceptible  to  those  diseases.  Such  peculiarity 
produces  a  tendency  to  a  disease,  rather  than  the 
disease  itself.  If  the  individual  inherits  from  one 
parent  a  sound  tissue  condition,  one  inimical 
to  the  development  of  a  given  disease,  we  may 
never  see  in  the  child  any  tendency  manifested 
toward  that  disease.  This  principle  undoubtedly 
explains  why  some  children  escape  a  disease 
whose  appearance  we  have  much  reason  to  expect. 
It  is  quite  true  that  it  is  easier  to  be  certain  of  the 
actual  presence  of  a  disease  in  a  person,  than  to 
know  that  he  really  has  no  tendency  to  it.  Never- 
theless, the  complete  absence  of  a  disease  in  a 
family  or  an  individual  is  an  element  of  decided 
importance.  Absence  of  a  disease  in  one  branch 
of  a  family  is  of  particular  importance,  if  it  is 
evident  that  the  child  decidedly  resembles  that 
branch  of  the  family,  rather  than  the  other,  in 
which  the  disease  may  have  existed.  The  resem- 
blance to  one  parent,  and  to    the    family  of  that 


320  HOW   TO    KEEP   AVELL 

parent,  is  sometimes  very  striking.  It  is  usually 
not  alone  confined  to  features  and  physical 
appearance,  but  is  also  seen  in  temperament  and 
behaviour  under  disease  influences. 

2.  A  tendency,  even  if  slight,  if  it  exists  in 
both  parents,  may  appear  in  a  child  in  an  exagger- 
ated degree. 

This  principle  accounts  for  the  strong  tendencies 
which  sometimes  appear  in  children  when  the 
family  history  shows  but  slight  tendency  in  that 
direction  on  either  side.  A  father  and  mother, 
for  example,  who  are  moderately  rheumatic, 
may  have  a  child  who  is  extremely  rheumatic. 
Had  one  of  these  parents  been  a  member  of  a 
non-rheumatic  family,  the  child  might  have 
escaped,  perhaps  with  a  less  rheumatic  tendency 
than  that  exhibited  by  the  other  parent.  When 
a  tendency  to  a  given  disease  or  a  given  tempera- 
ment is  strongly  marked  in  both  parents,  the  child 
rarely  escapes.  The  inherited  tendency  in  such 
conditions  is  frequently  so  great  as  to  cause  serious 
physical  or  mental  aberration.  One  of  the  causes 
of  degeneracy  is  this  combined  inheritance  of 
grave  pathological  physical  or  mental  conditions. 

3.  Heredity  is  strongly  modified  by  a  powerful 
tendency  on  the  part  of  nature  to  preserve  the  type 
of  each  family  and  species. 


HEREDITY  321 

Permanence  of  type  is  one  of  the  most  unchange- 
able laws  of  nature.  Abnormahties  and  exceptions 
may  occur,  but  the  tendency  is  not  to  their  repe- 
tition, but  rather  to  reversion  to  the  original  type. 
Abnormal  cases,  while  they  evince  sometimes  a 
strong  tendency  to  reproduce  themselves,  are 
continuously  under  the  influence  of  this  law. 
The  child  of  a  talented  man  is  frequently  as  talented 
as  his  parent,  but  the  child  of  a  great  genius  is 
rarely  a  genius.  The  genius  is  an  anomaly,  and 
his  child  tends  to  revert  to  the  average  type. 
Genius  does  not  appear  in  the  same  family  genera- 
tion after  generation,  but  talent  shows  a  strong 
tendency  to  concentrate  itself  in  families.  The 
number  of  talented  families  is  undoubtedly  in- 
creasing. 

As  a  further  example,  take  the  question  of  bodily 
height,  upon  which  accurate  observation  is  easy. 
It  has  been  demonstrated  by  scientific  observation, 
that  the  children  of  tall  parents  are  generally 
shorter  than  the  parents,  and  the  children  of  short 
parents  are  gerterally  taller.  Professor  Wilson 
affirms  that  there  is  a  strong  tendency  to  keep  the 
average  height  of  five  feet  eight  and  one-half 
inches.  These  are  examples  of  a  law  which  has  a 
very  wide  application.  Nature,  while  she  per- 
mits infinite  diversity  and  encourages  individuality, 


322  HOW    TO    KEEP    WELL 

even  to  the  extent  of  tolerating  many  exceptions 
and  anomalies,  is  strongly  adverse  to  their  repe- 
tition, and  permits  no  long-continued  wandering 
from  the  limits  of  the  type. 

A  study  of  species  shows  that  the  whole  tendency 
of  evolution  has  been  upward.  "No  type  of 
organization,"  says  Winchell,  "having  once  entered 
the  portal  of  a  higher  life,  has  been  permitted 
to  retreat."  The  genus  homo  is  no  exception 
to  this  rule.  It  has  steadily  advanced  through 
the  ages,  each  race  ever  keeping  within  the  limits 
of  its  own  type.  "No  new  race,"  says  Topinard, 
"having  characters  other  than  those  of  the  mixed 
races,  has  been  created  within  our  knowledge." 
Evolution  has  ever  been  from  a  lower  to  a  higher 
type.  There  is  no  evidence  to  show  that  this 
great  law  of  nature  has  been  reversed  in  our  own 
generation.  It  is  true  that  we  see  many  examples 
of  individual  degeneracy,  but  it  has  not  been 
demonstrated  that  they  are  more  common  now 
than  in  the  past.  What  is  true  in  the  larger  field 
of  races  is  also  true  in  the  more  limited  one  of 
nationality,  tribe,  and  family.  Nature  is  still 
very  tenacious  of  the  type,  and  preserves  it  un- 
changed through  passing  generations.  The 
experience  of  the  practising  ph3rsician  confirms 
this.     While  he  sees  numerous  examples  of  inher- 


HEREDITY  323 

ited  taint  and  congenital  defects,  he  also  sees 
defects  in  tlie  parents  obliterated  in  the  children. 
He  sees  neuroses  in  one  generation  appearing  in 
milder  form  in  the  next,  or  disappearing  altogether. 
He  sees  children  who  are  stronger  and  more  robust 
than  either  parent. 

It  is  a  mistaken  conception  that  hereditary 
tendency  is  only  toward  the  bad  and  away  from 
the  good.  There  are  two  well-defined  tendencies 
in  heredity — the  one  toward  the  normal,  the  other 
toward  the  abnormal.  These  tendencies  are  con- 
stantly at  strife.  Had  the  stronger  tendency  not 
been  to  revert  to  the  normal  type,  the  course  of 
the  race  would  not  have  been  toward  advance- 
ment, but  to  steady  and  continuous  degeneration, 
and  to  final  extinction. 

4.  Hereditary  influences  are  not  all  apparent  in 
infancy,  or  at  an 3^  other  particular  age,  but  certain 
tendencies  appear  at  certain  periods  of  life,  and 
frequently  disappear  when  that  period  is  passed. 

Parents  frequently  express  surprise  that  their 
infants  exhibit  tendencies  or  show  weak  points 
which  they  themselves  do  not  possess.  The  grand- 
mother sometimes  explains  the  matter  by  saying 
that  one  of  the  infant's  parents  showed  the  same 
traits  when  a  baby.  On  the  other  hand,  an  infant 
often   fails    to    show    conditions   which   might   be 


324  HOW    TO    KEEP    WELL 

expected  if  one  did  not  study  the  hereditary 
tendency  of  the  family.  Such  conditions  may  not 
develop  until  late  in  life. 

Even^  individual  must  pass  through  certain 
periods  of  development  before  full  maturity  of 
mind  and  body  is  reached.  This  requires  about 
twenty-five  years.  No  argument  is  necessary  to 
prove  that  this  developmental  period  is  a  most 
important  one  in  the  life  of  an  individual.  While 
this  is  true  of  all  the  organs  and  systems  of  the 
body,  it  is  particularly  so  of  the  nervous  system. 
Many  organs  act  as  perfectly  in  infancy  as  in 
adult  life,  but  the  brain  requires  3^ears  to  develop 
its  functional  activity.  A  child  comes  into  the  world 
with  one-third  the  volume  of  his  brain ;  he  acquires 
the  second  third  before  twelve  months  are  passed, 
and  the  rest  between  that  time  and  the  twenty-first 
vear.  Herein  lies  the  great  difference  between  the 
nervous  system  and  every  other  system  of  the  body. 
Its  physical  development  more  than  keeps  pace 
with  that  of  the  body  at  large,  but  its  functional 
development  is  exceedingly  slow,  requiring  years 
for  its  completion. 

The  higher  we  go  in  the  scale  of  civilization,  the 
more  prolonged  is  the  period  of  functional  growth. 
It  is  easy  to  understand,  therefore,  why  so  many 
different    nervous    diseases    develop    at    different 


HEREDITY  -325 

periods,  and  why  so  many  defects  appear  for  the 
first  time  at  varying  intervals  during  a  space  of 
twenty  or  twenty-five  years.  The  brain  has 
certain  well-defined  stages  and  periods  of  develop- 
ment, and  various  forms  of  nerve  disorders  appear 
as  these  stages  are  reached. 

A  study  of  the  developmental  periods  of  life 
elucidates  many  obscure  phases  of  disease  during 
childhood  and  youth.  Certain  defects  are  char- 
acteristic of  certain  periods  and  invariably  develop 
within  certain  age  limits.  Doctor  Clouston,  of 
Edinburgh,  has  described  these  periods  with 
great  clearness.  The  first  is  the  embryonic. 
Inability  to  complete  the  various  processes  through 
which  the  organs  attain  their  gro^iih  must  result 
in  grave  and  radical  defects,  both  physical  and  men- 
tal. These  defects  are  seen  when  the  child  is 
born.  At  birth  a  grave  crisis  occurs  in  the  life  of 
the  individual.  It  is  then  to  be  determined 
whether  the  development  of  the  various  organs 
is  sufficiently  perfect  to  maintain  independent 
life.  In  many  cases  the  test  is  too  severe,  and  the 
infant  dies  from  innate  defects,  and  inability  to 
adapt  itself  to  the  new  conditions. 

The  next  period  that  brings  out  the  defects  of 
bad  heredity  is  that  of  rapid  brain  growth,  which 
extends  from  birth  to  about  seven  vears.     This  is 


326  HOW    TO    KEEP   WELL 

the  period  of  special  sense  education,  motor  coor- 
dination, and  speech.  The  abnormal  conditions 
incident  to  this  stage  are  convulsions,  night  ter- 
rors, infantile  paralysis,  stammering,  strabismus, 
hydrocephalus,  liability  to  sudden  rises  of  tempera- 
ture, and  numerous  other  abnormalities.  Most  of 
these  are  associated  more  or  less  closely  with  the 
great  brain  growth  and  the  development  of  certain 
brain  functions,  such  as  speech  and  equilibrium.     - 

The  next  period  extends  from  seven  to  thirteen 
years,  when  muscular  motion  becomes  fully  coor- 
dinated with  emotion,  as  seen  in  facial  expression. 
The  diseases  especially  incident  to  this  period 
are  chorea  (Saint  Vitus 's  dance),  epilepsy,  som- 
nambulism, migraine,  and  certain  eye  defects, 
especially  near-sightedness. 

The  last  period  extends  from  thirteen  to  twenty- 
five,  and  is  marked  by  the  emotional  and  moral 
development  that  centre  around  this  time  of  life. 
We  may  now  have  hysteria,  epilepsy,  eccentricity, 
and  certain  forms  of  emotional  wilfulness  and  moral 
perversion.  While  the  boundary  lines  of  these 
various  periods  are  neither  exact  nor  well  defined, 
much  may  be  learned  regarding  the  various  diseased 
conditions  of  early  life  by  due  consideration  of 
such  a  classification. 

Heredity  is  a  very  potent  predisposing  cause  in 


HEREDITY  327 

nearly  all  the  nervous  disorders  common  to  the 
developmental  period  of  life.  In  a  few  instances, 
it  is  the  only  cause,  neurotic  conditions  being 
inevitable  during  growth  and  development.  In 
most  cases,  however,  heredity  can  only  be  con- 
sidered a  predisposing  cause,  some  exciting  cause 
being  necessary  to  waken  the  disease  into  activity. 
The  possibilities  of  prevention  are  many,  and  it 
is  here  that  preventive  medicine  may  find  some  of 
its  greatest  opportunities.  In  spite  of  all  that  can 
be  done,  however,  many  must  suffer.  Their  fate 
was  sealed  before  birth,  and  no  skill  can  overcome 
the  defects.  Nevertheless,  something  can  be  done 
for  all,  and  some  can  be  saved  entirelv. 

No  better  advice  has  ever  been  formulated 
than  that  given  by  Doctor  Clouston:  "Build  up 
the  bone  and  fat  and  muscle,  especially  the  fat, 
during  the  periods  of  growth  and  development. 
Make  fresh  air  the  breath  of  life  to  the  young. 
Develop  lower  centres,  rather  than  higher  ones. 
Do  not  give  too  much  nitrogenous  food  during 
growth  and  adolescence,  as  being  a  special  stimu- 
lant to  the  higher  brain  and  to  the  too  early  devel- 
opment and  dominance  of  the  reproductive  func- 
tions. Avoid  alcohol  and  the  nervine  stimulants 
absolutely  if  possible.  Do  not  cultivate,  but  rather 
restrain  the  imaginative  and  artistic  faculties  and 


328  HOW   TO    KEEP    WELL 

sensitiveness,  and  the  idealisms^  generally,  in  the 
cases  where  such  tend  to  appear  too  early  and  too 
keenly.  They  will  be  rooted  on  a  better  brain-and- 
body  basis  if  they  come  later.  Cultivate  and  insist 
on  orderliness  and  method  in  all  things.  The 
weakly  neurotics  are  always  disorderly,  unbusi- 
nesslike, and  unsystematic.  Fatness,  self-control, 
and  orderliness  are  the  three  most  important 
qualities  for  them  to  aim  at." 

It  is  evident  that,  while  heredity  is  a  positive 
and   important    factor   in   the   making   up    of   our 
characters,  it  is  not  what  many  suppose  it  to  be. 
Knowledge    and    culture    are    not    inherited,    but 
depend   upon   education,    influence,    and   environ- 
ment.    Mental  capacity  for  culture  is  transmitted. 
Heredity    has,    in  fact,  been  defined  as  "original 
capacity    and    original    limitations."     One    man 
inherits  a  capacity  to  do  great  things,  but  it  must 
be  nurtured  and  developed  or  the  great  things  will 
never  be   done.     He  may   inherit   a   capacity  for 
learning,  but  he  must  study  and  be  instructed  or 
he   will    not    become    learned.     Another    has   had 
hereditary  limitations  put  upon  him  which  ever 
restrict   him   within   certain   channels   and   forbid 
him    to    go    beyond    certain    boundaries.     We    all 
have    our    limitations.     In    some    they    are    very 
narrow,    in    others    very    broad.     As    in    mental 


HEREDITY  329 

qualities,  so  it  is  in  physical.  Tuberculosis, 
insanity,  gout,  and  other  diseases  are  not  inherited 
any  more  than  are  education  and  culture,  but  rather 
certain  hereditary  tendencies  or  tissue  conditions 
which  may  be  readily  evoked  if  exciting  causes 
are  brought  to  bear. 

These  various  predispositions  may  be  trans- 
mitted, but  there  is  no  certainty  that  they  will  be 
in  any  individual  case.  The  parent  is  in  a  certain 
sense  a  trustee,  and  transmits  to  his  child  largely 
what  he  has  received  from  his  ancestors.  One 
parent  may  thus  increase  or  limit  the  inheritance 
that  would  come  from  the  other.  Heredity  is, 
then,  the  transmission  of  certain  capacities,  pre- 
dispositions, and  tendencies ,  upon  which  are  placed 
certain  original  limitations. 


CHAPTER   XIII 
Regimen  of  Adult  Life 

"Nothing  conduces  more  to  Health  and  Long 
Life,  than  Abstenance  and  plain  Food,  with  due 
Labour.  When  exercise  is  wanting  (as  in  studious 
persons)  there  is  greater  need  of  Abstenance,  and 
tender  Persons  ought  to  use  as  much  Abstenance 
as  they  possibly  can.  As  to  the  amount  of  Food, 
Nature  requires  no  Mathematical  Exactness.  A 
plain  rule  for  judging  of  the  Quantity  is,  not  to 
eat  so  much  as  indisposes  for  business."  Thus 
wrote  wise  old  George  Cheyne,  in  that  remarkable 
"Essay  on  Health  and  Long  Life,  printed  at  the 
Golden  Ball  over  against  the  Royal  Exchange  in 
Cornhill,  1725." 

It  is  difficult  to  write  wisely  and  well  on  diet. 
It  is  still  more  difficult  to  write  in  a  manner  that 
will  not  evoke  criticism  from  some  quarter.  Upon 
few  other  subjects  is  there  greater  diversity  of 
opinion  or  tendency  to  extreme  and  radical  views. 
Nothwithstanding  the  fact  that  digestion  con- 
sists of  a  series  of  complex  chemical  processes, 
people  with  no  chemical  knowledge  whatever  are 

330 


REGIMEN    OF    ADULT    LIFE  331 

often  heard  to  enunciate  the  most  positive  but 
extraordinary  views  upon  the  subject.  In  fact, 
extreme  and  pecuHar  views  seem  prone  to  follow 
a  study  of  dietetics  by  the  average  individual. 
He  is  apt  to  adopt  some  peculiar  school  or  doctrine, 
and  to  become  more  extreme  the  longer  his  mind 
dwells  upon  the  subject.  "An  exclusive  and 
sectarian  spirit  always  creeps  in,"  says  Sir  Henry 
Thompson,  "wherever  an  'ism'  leads  the  way, 
which  sooner  or  later  brings  in  its  train  assertions 
barely  supported  by  fact,  the  equivocal  use  of 
terms,  evasion — in  short,  untruthfulness,  unin- 
tended and  unperceived  by  the  well-meaning 
people  who  have  adopted  the  'ism.'  At  last  they 
suffer  unconsciously  from  obscurity  of  vision,  and 
are  in  danger  of  becoming  blind  partizans." 

Surprise  is  sometimes  expressed  that  dietetics 
receives  so  little  attention  from  educated  people. 
One  reason,  no  doubt,  is  the  fact  that  so  much 
that  is  written  upon  the  subject  is  impractical  and 
foolish.  Looking  at  random  into  a  recent  number 
of  one  of  the  leading  journals  on  hygiene,  we  find 
that  the  first  article  gives  numerous  dietetic  rules, 
some  of  them  admirable  in  the  extreme.  But  at 
the  outset  we  find  the  following:  "Never  eat 
when  in  a  hurry.  Take  no  vigorous  exercise, 
either  mental  or  physical,  for  half  an  hour  before  a 


Z^2  HOW   TO    KEEP   WELL 

meal,  and  for  at  least  one  hour  afterward."  This 
is  good  advice  for  those  who  have  leisure,  but  how 
about  the  ninety  and  nine  in  every  hundred  toilers 
of  this  workaday  world — the  business  men, 
lawyers,  doctors,  housewives,  mothers  of  families, 
clerks,  shop-girls,  and  manual  labourers.  They 
must  eat  when  they  can,  and  must  then  go  to  work. 
Nuts,  this  article  says,  are  better  than  meat.  The 
nut  fad  now  in  vogue  is  very  foolish.  Still  further 
it  says,  "when  a  dessert  is  served,  a  good  plan  is 
to  have  it  at  the  commencement  of  the  meal; 
there  is  less  danger  of  overeating."  This  is  true 
to  an  extreme  degree.  Dessert  at  the  outset  could 
be  relied  upon  to  put  a  damper  on  any  appetite. 
It  is  such  advice  as  this  that  gives  many  people 
the  feeling  tliat  dietetics  is  a  system  cunningly 
devised  for  cranks,  and  a  few  individuals  of  the 
leisure  class. 

To  allay  any  apprehension,  therefore,  let  it  be 
fully  understood  at  once  that  no  "system"  of 
dietetics  is  to  be  proposed  here,  and  no  food  or 
class  of  foods  is  to  be  advocated  as  capable  of 
relieving  all  the  ills  of  human  flesh.  On  the  con- 
trary, let  us  start  with  the  fundamental  propo- 
sition that  it  is  wise  to  utilize  as  many  as  we  pos- 
sibly can  of  the  good  things  given  to  men  by  a 
bountiful   Providence.     We  may   not   want   them 


REGIMEN  OF  ADULT  LIFE  s:^^ 

all  ourselves.  We  may  not  wish  to  eat  whale 
blubber  or  sharks'  fins,  but  let  us  leave  them  to 
the  Eskimo  and  the  Chinaman. 

It  is  not  desirable  to  confine  ourselves  to  a  single 
article  of  diet,  or  even  to  the  same  classes  of  foods. 
There  is  scarcely  a  food  in  general  use  that  has  not 
sonie  good  point,  and  few  that  may  not  be  used 
by  some  individuals.  In  variety  there  is  health, 
and  a  table  that  offers  a  variety  from  day  to  day 
is  the  one  at  which  the  best  appetites  and  digestion 
will  be  found.  The  appetite  is  prone  to  fail  when 
the  same  things  appear  day  after  day,  though  the 
variety  be  large.  This  is  often  seen  at  the  hotel 
table,  where  the  menu  is  usually  larger  than  that 
of  the  home  table.  At  first  the  variety  seems 
large,  and  the  appetite  is  stimulated,  but  the  same- 
ness becomes  wearisome  after  a  little  time,  and  the 
appetite  is  apt  to  diminish.  A  few  well-selected 
dishes,  with  changes  from  day  to  day,  is  better 
for  the  digestion,  as  well  as  for  the  appetite,  than  a 
throng  of  articles  appearing  repeatedly.  If  the 
diet  be  too  much  restricted,  the  stomach  adapts 
itself  to  its  limited  work  and  loses  the  power  to 
digest  other  food  well.  ]\Ian  was  undoubtedly 
designed  by  nature  as  an  omnivorous  animal,  and 
he  should  have  a  mixed  and  varied  diet. 

For  an  understanding  of  the  subject  of  diet  a  few 


334  HOW    TO    KEEP    WELL 

words  are  necessary  upon  the  chemistry  of  foods, 
which  are  mixtures  of  various  animal,  vegetable, 
and  mineral  principles.  The  chief  mineral  prin- 
ciples are  water  and  common  salt.  The  animal 
and  vegetable  principles  are  three  in  number — 
albuminoids,  fats,  and  Carbohydrates.  Albumin- 
oids are  the  nitrogen  foods,  the  most  important  of 
which  are  albumin  and  fibrin.  They  form  an 
important  part  of  animal  food  and  occur  also  in 
certain  vegetables.  The  fats  are  derived  from 
both  the  animal  and  vegetable  kingdoms.  The 
carbohydrates  include  the  sugars  and  starches, 
which  are  closely  related.  It  was  formerly  the 
teaching  that  albuminoids  are  devoted  exclusively 
to  the  building  up  of  tissue  and  muscle,  and  the 
other  two  elements  to  the  production  of  heat  and 
force.  While  this  is  largely  true,  their  line  of 
action  is  not  closely  marked.  Properly  constituted 
food  should  contain  a  due  proportion  of  each  of 
these  elements.  As  this  condition  exists  in  no 
single  food,  a  mixed  diet  is  necessary.  No  one 
food,  even  though  it  contains  all  these  elements, 
has  them  in  the  proper  proportion  for  the  adult. 
Milk,  which  is  most  nearly  a  perfect  food,  is  pro- 
portioned to  the  needs  of  the  infant,  not  the  adult. 
In  vegetable  foods,  as  a  rule,  the  carbohydrates  pre- 
dominate ;  in  animal  foods,  the  fats  and  albuminoids. 


REGIMEN    OF   ADULT    LIFE  335 

Most  albuminoids  of  animal  origin  are  digested 
more  readily  and  more  completely  than  are  those 
of  vegetable  origin.  Animal  fats  are  digested  more 
readily  than  are  vegetable  fats,  chiefly  because  of 
the  cellulose  coverings  of  the  latter.  The  large 
amount  of  starch  contained  in  many  vegetable 
foods  tends  to  produce  in  the  stomach  an  acid 
fermentation.  Uncooked  starch  is  indigestible 
because  the  starch  grains  are  surrounded  by  a 
tough  capsule  which  the  digestive  fluids  cannot 
penetrate.  This  capsule  is  broken  by  heat. 
Baked,  or  so-called  roasted  foods,  which  are  sub- 
jected to  a  high  degree  of  heat  in  the  oven,  are 
■usually  more  digestible  than  boiled  food,  which  has 
been  raised  only  to  the  temperature  of  boiling 
water. 

Animal  food  has  a  distinctly  stimulating  prop- 
erty, owing  to  crystalline  bodies  which  are  con- 
tained in  the  muscle  serum.  This  property  may  be 
in  some  cases  advantageous,  in  others  detrimental. 
Properly  selected  vegetable  food  certainly  contains 
all  the  primary  food  principles.  The  fact  that 
certain  individuals  live  in  health  without  animal 
food  simply  proves  that  vegetarianism  can  be  toler- 
ated. It  does  not  prove  that  it  is  best.  There 
are,  however,  very  few  strict  vegetarians.  Most 
of  those  calling  themselves  by  that  name  simply 


336  HOW   TO    KEEP   WELL 

eliminate  meat  from  their  diet.  They  eat  milk, 
eggs,  butter,  cream,  and  even  cheese — concentrated 
forms  of  animal  food.  Some  do  not  even  eliminate 
fish,  shell  fish,  and  animal  jellies.  This  is  men- 
tioned not  to  criticize  the  use  of  these  foods,  but 
rather  to  protest  against  the  adoption  of  the  word 
vegetarian  by  those  who  eat  every  day  large 
quantities  of  animal  food.  If  most  of  the  systems 
of  diet  alleged  to  be  vegetarian  are  really  such, 
then  the  infant  at  the  breast  is  also  a  vegetarian. 
The  person  who  eliminates  meat,  fish,  poultry,  eggs, 
cheese,  milk,  butter,  and  all  animal  food  from  his 
diet,  may  call  himself  a  vegetarian.  If  he  adopts 
that  title  without  doing  so,  he  is  sailing  under  false 
colours. 

The  physiology  of  digestion  is  quite  complicated, 
and  difficult  to  explain  in  a  popular  manner.  It 
begins,  or  should  begin,  in  the  mouth,  where  the 
starch  begins  to  be  changed  by  the  saliva  into 
sugar.  Starch  is  not  used  as  such  by  the  body, 
but  is  converted  into  one  form  of  sugar,  of  which 
there  are  several.  Sugar  is  soluble,  and  difficult 
of  preservation.  Starch  is  insoluble,  and  can  be 
preserved  indefinitely.  Hence,  by  a  wise  provision 
of  nature,  most  plants  change  their  sugar  into 
starch  and  then  store  it  up.  By  another  wise  pro- 
vision   mrm    has    been    given    the    appliances    for 


REGIMEN    OF    ADULT    LIFE  337 

changing  the  starch  back  into  soluble  sugar  for 
his  own  use.  As  these  appliances  are  quite  com- 
plex, and  not  in  working  order  until  the  latter  half 
of  the  first  year,  the  baby  is  given  a  liberal  supply 
of  sugar,  not  starch,  in  the  form  of  milk  sugar, 
which  is  easily  absorbed.  We  see  here  another 
wise  provision.  If  the  baby  is  fed  upon  a  mod- 
ern improved  food  with  unchanged  starch  in  it, 
the  only  thing  he  can  do  is  to  let  it  ferment  in 
his  stomach  and  cause  colic,  because  he  cannot 
digest  it. 

In  the  stomach  the  albuminoid  elements  (the 
lean  meat  and  white  of  eggs)  are  digested.  Here 
the  food  is  broken  up  because  the  fibrous  structures 
which  bind  it  together  are  disintegrated:  another 
wise  provision.  In  fact,  as  one  progresses  in  the 
study  of  anatomy,  physiology,  and  chemistry,  and 
sees  how  they  are  interwoven  to  form  mechanisms 
of  marvelous  perfection,  he  becomes  impressed 
with  the  number  of  wise  provisions  he  meets  at 
every  step.  This  breaking  up  of  the  connective 
tissues  liberates  the  fats  and  starches  and  renders 
their  digestion  possible  farther  on  in  the  digestive 
tract. 

From  the  stomach  an  excess  of  fluid  is  absorbed, 
together  with  certain  digested  matters,  and  is 
taken  by  the  portal  vein  to  the  liver.     Alcohol  is 


338  HOW   TO    KEEP   WELL 

thus  absorbed.  Hence,  the  unwisdom  of  drinking 
it  before  breakfast  or  upon  an  empty  stomach.  It 
is  taken  undiluted  direct  to  the  hver,  where  it 
expends  its  whole  deleterious  force  upon  that 
organ.  Upon  leaving  the  stomach,  the  food  enters 
the  duodenum,  or  upper  portion  of  the  small  bowel. 
Here  the  starch,  whose  digestion  was  slightly  begun 
by  the  saliva,  is  fully  digested  by  being  converted 
into  sugar.  The  fat  is  broken  up  into  minute 
particles  and  converted  into  an  emulsion,  in  which 
form  it  is  readily  absorbed. 

The  digested  portions  of  the  food,  being  absorbed, 
must  be  acted  upon  by  the  liver  and  other  glands, 
which  are  known  as  the  organs  of  assimilation. 
The  liver  is  in  close  proximity  to  the  stomach  and 
duodenum,  and  is  closely  associated  with  them  in 
the  work  of  digestion  and  assimilation.  Disorders 
of  one,  unless  very  transient,  are  usually  accom- 
panied by  disorders  of  the  others.  "Indigestion" 
is  rarely  a  simple  condition  limited  completely  to 
one  of  the  digestive  organs.  Sometimes  in  chronic 
cases  the  symptoms  due  to  one  will  predominate, 
and  at  other  times  those  due  to  another.  Now  it 
may  be  the  stomach  which  causes  the  most  trouble ; 
another  time  bowel  indigestion  may  predominate; 
at  another  time  the  liver  may  be  the  most  promi- 
nent   offender.     The    liver,    however,    is    charged 


REGIMEN    OF    ADULT    LIFE  339 

with  many  sins  it  never  commits.  To  the  question, 
"Is  hfe  worth  Hving?"  the  answer  has  been  given, 
"It  all  depends  on  the  liver. "  It  is  a  good  pun, 
but  not  very  good  science. 

Let  no  one  think  that  long  years  of  dietetic 
sinning  can  be  atoned  for  by  a  few  weeks  of  correct 
living.  As  explained  in  another  chapter,  the  body 
is  not  an  inanimate  machine,  in  which  perverted 
action  is  always  corrected  wdien  the  cause  is 
removed.  The  persistent  eating  of  improper  food 
and  too  much  food  causes  fermentation,  and  the 
production  of  gases  and  acid  substances.  These 
in  turn  irritate  the  digestive  organs  and  cause  their 
secreting  glands  to  act  in  an  abnormal  manner. 
Catarrhal  conditions  soon  follow.  This  in  its  turn 
diminishes  the  digestive  power  and  causes  oppres- 
sion, distension,  or  actual  pain,  and  so  the  "vicious 
circle"  is  completed.  Indigestion  causes  inflamma- 
tion and  perverted  action;  inflammation  and  per- 
verted action  cause  indigestion.  Finally,  the 
stomach  and  bowels,  through  persistent  distension, 
lose  their  muscular  tone,  and  become  dilated  and 
flabby;  their  mucous  membranes  are  inflamed 
and  sore;  their  secreting  power  is  diminished.  The 
strength  fails,  and  the  patient  becomes  thin,  irri- 
table in  temper,  and  despondent — in  fact,  a  chronic 
dyspeptic. 


340  HOW   TO    KEEP   WELL 

Such  organic  conditions  cannot  be  cured  by  a 
few  weeks  of  rational  diet.  The  sore  organs  will 
grumble  at  the  most  perfect  diet  that  can  be 
devised,  and  in  many  cases  the  stomach  will  "gnaw 
upon  itself,"  and  ache  when  empty.  In  many 
instances  the  adoption  of  a  proper  diet,  if  per- 
sisted in,  despite  discouragements  which  will  con- 
stantly come,  will  result  in  final  cure.  The  cure 
may  usually  be  aided  by  judicious  treatment,  a 
change  of  scene,  relief  from  work  and  care,  and 
tonics.  In  the  more  severe  and  chronic  cases  the 
organic  changes  are  so  pronounced  that  change  of 
diet  alone  is  not  adequate.  Special  measures  are 
necessary,  and  tonic  treatment  in  the  broadest 
sense  is  required. 

Improper  diet  is  not  the  only  cause  of  dyspepsia. 
Prolonged  worry  and  anxiety,  overwork,  with 
hurried  and  irregular  meals,  or  malnutrition  result- 
ing from  disease,  may  cause  it.  The  miother  of  a 
large  family  with  slender  means,  who  must  all  the 
time  overdo  her  strength,  eat  hurriedly,  and  bear 
the  multitudinous  worries  from  which  she  can 
never  escape,  may  become  dyspeptic  on  a  well- 
selected  diet.  Compression  of  the  stomach  is  a 
frequent  source  of  dyspepsia.  The  literary  man, 
the  bookkeeper,  and  the  business  man  who  allows 
himself  to  sit  at  his  desk  in  a  fallen-together  atti- 


REGIMEN    OF   ADULT    LIFE  341 

tude,  may  become  dyspeptic  from  that  cause  alone. 
The  same  is  true  of  seamstresses  and  all  workers 
who  are  obliged  to  lean  forward  at  their  work. 
While  the  diet  in  these  various  individuals  usually 
recjuires  correction,  no  change  in  the  diet  alone 
will  effect  a  cure.  Unless  a  better  attitude  is 
assumed,  and  the  pressure  is  taken  from  the 
stomach,  the  dyspepsia  will  not  entirely  cease. 
One  of  the  most  potent  causes  predisposing  to 
dyspepsia  is  tight  lacing,  by  which  the  stomach  is 
compressed  and  often  displaced.  The  stomach, 
duodenum  and  liver  are  the  organs  occupying  a 
position  to  be  most  affected  by  this  pernicious 
habit. 

"Dyspepsia"  is  a  popular  term  used  to  designate 
complex  and  multiform  conditions,  which  may 
result  from  inflammation  of  one  or  more  of  the 
organs  of  digestion  or  perversion  of  their  secretions, 
or  from  the  presence  of  ferments  and  bacteria. 
And  know,  ye  dyspeptic,  that  there  is  no  short  and 
easy  road  to  cure  by  pepsin,  pancreatin,  and 
patent  tablets  and  elixirs.  The  remedy  that 
relieved  your  neighbour,  with  his  excess  of  muriatic 
acid  in  the  gastric  juice,  may  be  poison  for  you  in 
whom  it  is  deficient.  His  sour  stomach  may  have 
been  due  to  too  much  natural  acid,  yours  to  butyric 
acid,    the    result    of    putrefaction.     Dyspepsia    is 


342  HOW   TO    KEEP   WELL 

usually  due  to  errors  of  diet  as  an  exciting  cause, 
following  upon  numerous  predisposing  causes.  It 
can  be  relieved  by  medicine,  but  cured  only  by 
removing  the  causes.  That  being  done,  treatment 
judiciously  prescribed  may  hasten  the  cure,  and  in 
some  cases  may  be  necessary  for  its  accomplish- 
ment. It  is  due  to  so  many  causes,  and  is  charac- 
terized by  so  many  complex  conditions,  that  it  is 
folly  to  suppose  that  every  case  can  be  cured  by 
the  same  means,  or  that  any  system  of  treatment 
will  be  efficient  in  all  conditions.  It  is  impossible 
to  prescribe  diet  without  knowing  the  peculiarities 
of  each  individual  case  and  studying  the  question 
of  personal  idiosyncracy.  An  attempt  has  been 
made  in  this  and  the  following  chapter,  however, 
to,  give  directions  for  the  various  conditions  which 
an  intelligent  person  can  adapt  to  his  own  require- 
ments. 

In  deciding  upon  the  quality  and  quantity  of 
food  required  by  an  individual,  many  factors  must 
be  considered.  Climate,  season,  age,  mode  of  life, 
previous  habits,  character  of  exercise,  occupation, 
and  personal  peculiarities  must  all  be  considered. 
In  cold  climates,  and  during  the  winter  months  in 
the  so-called  temperate  zone,  there  is  a  demand 
for  much  animal  heat.  Heat-producing  foods 
are     indicated,    therefore.      The     Eskimo     enjoys 


REGIMEN    OF    ADULT    LIFE  343 

the  delicate  flavour  of  a  tallow  candle,  but  the 
Filipino  could  hardly  be  expected  to  appreciate  it. 
It  is  a  common  error  in  the  varied  climate  of  the 
northern  States  to  make  but  little  difference 
between  the  winter  and  summer  diet.  It  would 
be  manifestly  absurd  to  prescribe  the  same  diet 
for  the  Laplander  and  the  Hottentot.  And  yet 
the  extremes  of  temperature  between  our  "cold 
spells"  in  Avinter  and  "heated  terms"  in  summer 
are  almost  as  great  as  would  be  experienced  in 
going  from  Lapland  to  Africa.  It  is  my  firmly 
grounded  belief  that  a  moderate  and  rational 
amount  of  meat,  fat,  and  oil  is  advisable  in  the 
winter  diet  of  most  people.  In  the  summer  they 
should  be  diminished,  and  a  greater  proportion  of 
fruits,  vegetables,  and  cereals  should  be  taken. 
I\Ioreover,  the  quantity  of  aliment  should  be 
reduced  in  hot  weather. 

Age  is  another  important  element  in  the  selection 
of  diet.  Other  thingj  being  equal,  a  vigorous 
young  adult  requires  more  food  than  does  a  person 
in  middle  and  later  life.  The  rule  should  be,  after 
forty,  to  diminish  rather  than  increase  the  amount 
taken,  and  to  use  greater  caution  as  to  its  character. 
Rich,  made-up  dishes  should  be  avoided,  the  meat 
should  be  reduced,  and  pastry  and  rich  desserts 
should  be  taken  very   sparingly.     The   flues   and 


344  HOW    TO    KEEP    WELL 

waste-pipes  of  an  old  engine  are  more  readily 
clogged  than  are  those  of  a  new  one.  Your  body 
is  like  an  engine  in  that  you  are  taking  in  com- 
bustible material  which  is  utilized  in  the  produc- 
tion of  heat  and  energy.  If  you  take  in  too  much, 
the  unused  residue  must  remain  to  clog  various 
organs,  or  must  be  thrown  off,  thereby  placing 
undue  work  upon  others,  notably  the  kidneys. 
While  the  body  is  comparatively  new  it  will  do 
this  work  with  readiness.  The  time  will  come, 
however,  when  it  will  do  it  with  more  and  more 
difficulty,  and  the  point  may  be  reached  when  it 
is  not  equal  to  the  task,  and  what  we  call  disease 
is  the  result.  Hence  we  may  deduce  one  great 
principle  of  dietetics,  namely,  that  increasing  age 
demands  less,  not  more,  aliment. 

Occupation  is  an  element  of  the  greatest  impor- 
tance as  regards  the  diet.  A  change  in  occupation 
and  surroundings  is  frequently  not  properly  con- 
sidered. The  country  boy  on  the  farm,  who  eats 
fat  pork  and  pies  and  crullers  with  impunity, 
becomes,  if  transplanted  to  the  city,  a  dyspeptic 
on  a  much  more  digestible  diet.  The  labourer 
requires  more  food  than  the  student,  and  an 
entirely  different  food.  Those  engaged  in  active 
physical  labour  can  dispose  of  a  quantity  of 
nitrogenous  food,  malt  liquor  and  coffee  that  would 


REGIMEN   OF   ADULT   LIFE  345 

render  the  person  of  sedentary  habits  irreparably 
"bihous."  Muscular  activity  requires  not  only 
sugar  and  starch,  but  an  abundance  of  albuminous 
food. 

Idiosyncracy  must  explain  many  peculiarities, 
both  in  the  character  of  the  food  required  and  the 
amount  consumed.  Some  people  are  habitually 
hearty  eaters,  and  consume  large  quantities  of  food 
without  digestive  disturbance.  Others  are  habitu- 
ally small  eaters,  and  maintain  a  perfect  state  of 
health  on  a  surprisingly  meager  diet.  It  is  abso- 
lutely impossible  to  lay  down  any  rule  as  to  the 
amount  of  food  which  should  be  consumed  by  any 
particular  individual.  It  is  unnecessary  to  be 
worried  over  an  habitually  small  eater  as  long  as 
he  is  in  his  usual  health  and  his  general  condition 
is  good.  Many  a  fond  wife  and  mother  has  done 
her  husband  and  children  harm  by  persistently 
appealing  to  them  to  eat  beyond  their  requirements. 

The  diet  of  an  individual  is  determined  largely 
by  education,  social  standing,  and  the  habits  of 
those  by  whom  he  is  surrounded.  Habit,  in  fact, 
is  a  very  potent  factor  in  the  methods  of  life  of  all 
people.  Even  if  habits  of  diet  be  bad,  it  is  usually 
unwise  to  change  them  too  radically  and  too 
suddenly.  When  extreme  and  radical  changes 
seem  to  be  indicated,  it  is  advisable  to  make  them 


346  HOW   TO    KEEP   WELL 

gradually,  for  serious  results  sometimes  follow  the 
too  sudden  breaking  up  of  long-established  methods 
of  living.  It  is  habit  which  induces  people  to  go 
on  in  certain  methods  of  living  in  spite  of  changed 
conditions.  Methods  proper  under  some  con- 
ditions may  be  very  improper  under  others,  but  are 
perpetuated  simply  because  the  individual  has 
been  in  the  habit  of  doing  thus  and  so. 

Upon  no  question  in  dietetics  has  there  been 
more  discussion  or  more  extravagant  and  extreme 
views  expressed  than  upon  that  of  meat  eating. 
Without  entering  upon  this  controversy,  let  us 
adopt  a  standpoint  upon  middle  ground,  hoping 
that  it  is  the  golden  mean  where  the  most  truth  lies. 
This  ground  may  be  stated  as  follows:  Meat  is  a 
very  valuable  article  of  diet  of  which  many  Ameri- 
cans eat  altogether  too  much.  Properly  cooked 
meat  in  moderate  quantities  is  readily  digested 
by  most  healthy  stomachs.  It  contains  elements 
required  by  the  system,  notably,  the  albuminous 
or  nitrogenous  principles  which  are  used  in  muscle 
and  tissue  building  and  are  necessary  to  replace 
tissue  waste.  A  certain  proportion  of  such  ele- 
ments is  necessary  to  vigour  and  good  health. 
They  may  be  found,  it  is  true,  in  many  vegetables, 
but  the  animal  albuminoids  possess  properties  of 
peculiar    value.      Acknowledgment    of     this     fact 


REGIMEN    OF   ADULT   LIFE  347 

should  not  be  construed  into  the  theory  that  we 
cannot  eat  too  much  meat.  The  nitrogenous 
matters  of  the  food  must  pass  through  many 
complex  changes  before  they  can  be  eliminated 
from  the  body.  They  are,  indeed,  particularly 
difficult  elements  to  get  rid  of.  This  in  many 
cases,  rather  than  the  question  of  their  digestion, 
is  the  reason  for  curtailing  the  quantity  taken. 
Their  retention  in  the  body  increases  the  tendency 
to  uric  acid  and  the  gouty  and  rheumatic  condi- 
tions, and  places  additional  burdens  upon  the 
kidneys.  Hence,  their  excessive  use  may  not  be 
desirable,  even  if  they  are  well  digested. 

The  amount  of  muscular  exercise  must  deter- 
mine more  than  any  other  one  factor  the  amount 
of  meat  that  may  be  eaten.  The  less  the  exercise, 
the  less  the  meat.  "No  one  but  a  wood-chopper 
or  a  hunter  can  possibly  eat  red  meat  three  times 
a  day  without  inviting  uric  acid  to  come  and  take 
up  its  dwelling  in  his  system."  Gout  is  more 
common  in  this  country  than  is  usually  supposed, 
while  "poor-man's  gout,"  or  the  uric  acid  tendency, 
is  everywhere.  Meat  once  a  day,  at  dinner,  is  as 
much  as  most  well-to-do  denizens  of  the  city  can 
dispose  of.  Some  salt  meat  or  fish  at  breakfast  is 
not  precluded.  During  cold  weather,  or  when  some 
unusual  exercise  is  to  be  taken,  chops  or  steak  in 


348  HOW   TO    KEEP   WELL 

moderate  amount  may  be  added.  In  fact,  it  is 
often  better  to  take  meat  in  moderate  quantities 
twice  a  day  than  to  take  a  larger  amount  at  one 
time.  A  lesson  might  be  learned  by  the  three- 
times-a-day  meat  eater  by  watching  a  gang  of 
hardy  and  hard-working  Italians  at  their  luncheon, 
composed  chiefly  of  vegetable  food. 

It  is  difficult  for  those  accustomed  to  eat  meat 
three  times  a  day,  making  it  the  principal  article 
of  diet,  to  radically  change  their  habits.  The 
high  flavour  of  meat  and  the  dishes  containing  it 
make  other  diet  seem  insipid  and  tame.  The 
element  of  habit  is  here  very  strong.  It  can  be 
overcome,  however,  and  quantities  of  nutritious 
and  palatable  dishes  are  available  as  a  substitute 
for  meat.  AVith  milk,  butter,  and  eggs,  with  fish, 
shell-fish,  and  fowls,  with  vegetables,  cereals,  and 
fruits,  it  is  a  poor  cook  who  cannot  produce  a  palat- 
able and  sustaining  breakfast  and  lunch. 

This  meat  question  is  not  a  new  one,  as  shown 
by  the  following  quotation  from  George  Cheyne: 
"Much  animal  food  and  strong  liquors  seem  not  to 
have  been  designed  for  Man  in  his  Original  Make 
and  Frame,  but  rather  indulg'd  to  shorten  the 
Antediluvian  Length  of  Life,  in  order  to  prevent 
the  excessive  growth  of  Wickedness."  This  may 
certainly  be  used  in  support  of  the  theory  that  a 


REGIMEX    OF    ADULT    LIFE  349 

man's  conclusions  are  often  better  than  the  argu- 
ments he  uses  in  reaching  them. 

After  meat,  probably  the  most  frequently  dis- 
cussed and  most  maligned  article  of  diet  is  bread. 
"Throw  white  bread  to  the  dogs — though  it  will 
kill  them  if  fed  exclusively  on  it,"  says  a  recent 
health  journal.  And  so  will  brown  bread  and  any 
other  single  article  of  similar  character.  This  is 
a  fair  sample  of  the  kind  of  argument  used  against 
one  of  the  most  wholesome  and  valuable  articles 
of  diet  at  the  command  of  modern  man.  These 
attacks,  made  by  the  apostles  of  so-called  health 
foods,  are  injurious  in  the  extreme,  as  they  lead  to 
the  use  of  foods  inferior  in  every  respect  to  the 
one  they  attack.  AVheat  is  the  most  valuable 
cereal  that  has  been  known  to  man,  and  it  is  a  great 
blessing  that  in  recent  times  it  has  become  avail- 
able for  the  use  of  the  poorest.  Of  its  various 
products,  well-made  white  bread  is  the  best. 
But  we  are  told  with  great  positiveness  that  it 
will  kill  dogs.  AVe  must  eat  brown  bread  because 
it  contains  the  phosphates  and  mineral  matter. 
From  the  persistence  with  which  the  phosphates 
have  been  vaunted  by  the  health-food  writers  and 
patent  medicine  men  one  might  think  they  were 
the  most  important  elements  to  be  sought  in  diet. 
As    a    matter   of  fact,  thev   are   of  verv   moderate 


350  HOW   TO    KEEP   WELL 

value,  and  are  found  in  all  varieties  of  food  more 
commonly  than  any  other  mineral  element  except 
salt.  We  do  not  have  to  adopt  a  diet  of  husks  in 
order  to  get  them.  In  this  fair  land  of  ours, 
nature  has  been  so  generous  that  we  are  not  obliged 
to  eat  wheat  bran,  corn  husks,  or  nut  shells. 

The  prevalent  idea  that  whole  wheat  bread 
is  more  nutritious  than  white  bread  is  but 
one  of  many  errors  which  result  from  con- 
sidering only  the  chemical  composition  of  food. 
Although  chemical  analysis  shows  that  some 
forms  of  dark  bread  contain  a  little  more  nutrient 
than  does  white  bread,  digestive  experiments 
conclusively  show  that,  owing  to  the  cellulose  with 
which  a  part  of  that  nutrient  is  surrounded,  the 
dark  bread  is  not  as  completely  utilized  as  the 
white.  According  to  Bauer,  white  bread  is  utilized 
to  within  .8  or  1.6  per  cent.,  while  from  8  to  18  per 
cent,  of  dark  bread  is  unutilized.  A  European 
peasant  may  eat  soggy  black  bread  and  thrive  on 
it,  and  a  horse  can  digest  oats,  but  the  average 
American  can  eat  neither  the  one  nor  the  other 
with  profit.  By  modern  methods  of  milling,  white 
flour  is  very  constant  in  its  chemical  composition. 
It  consists  of  gluten  (nitrogenous  element),  starch 
(carbohydrate),  and  various  salts  (mineral).  It 
contains,  therefore,  in  ample  supply,  all  the  ele- 


REGIMEN    OF   ADULT    LIFE  351 

ments  of  a  complete  food  except  fat.  In  "bread 
and  butter,"  therefore,  we  have  so  complete  and 
so  excellent  a  food  that  it  has  been  very  well 
adopted  as  the  synonym  for  good  and  liberal  diet. 
Let  the  breadwinner  earn  his  bread  and  butter  and 
eat  it  with  his  family  without  misgiving  or  twinge 
of  conscience. 

There  can  be  no  objection  to  dark  bread  when  it 
is  well  made.  It  is  often  soggy  and  heavy,  so  that 
it  forms  a  doughy  and  indigestible  mass  in  the 
stomach.  Bread  that  is  light  and  dry  and  has 
plenty  of  crust  is  the  most  digestible.  AVhite 
bread  more  often  fulfils  these  requirements  than 
does  dark  bread.  The  kind  known  as  French 
bread  is  especially  digestible.  Most  people  tire 
of  the  dark  bread  as  they  do  not  of  the  white. 
But  few  can  use  it  exclusively,  year  after  year, 
without  losing  their  taste  for  it. 

Rice  is  used  by  a  greater  number  of  the  human 
family  than  any  other  cereal.  It  is  the  staff  of 
life  of  the  teeming  populations  of  the  Orient. 
While  it  contains  more  starch  than  any  other 
cereal,  it  has  but  a  trifle  of  fat  and  cellulose  and 
but  a  moderate  amount  of  albuminoid.  The 
starch  of  rice  is  very  digestible,  boiled  rice  being 
digested  in  an  hour.  Its  nutritive  value  is  less 
than  that  of  most  of  the  other  cereals,  notwith- 


352  HOW   TO    KEEP   WELL 

standing  the  fact  that  it  is  so  universally  employed 
in  eastern  countries.  In  those  countries  where  it 
is  used  so  largely  it  is  universally  combined  with 
oil  or  some  albuminoid  matter.  As  one  element 
in  the  diet,  rice  is  very  valuable,  and  might  be 
profitably  used  in  this  country  more  largely  than 
it   is. 

Indian  corn  contains  a  large  amount  of  starch 
and  considerable  fat.  It  is  somewhat  more 
nutritious  than  rice,  but  requires  an  interval  three 
times  as  long  for  its  digestion.  When  largely 
used  by  those  unaccustomed  to  it,  it  is  prone  to 
produce  intestinal  indigestion  and  diarrhea.  To 
furnish  a  complete  food,  corn  should  be  combined 
with  an  animal  albuminoid  and  a  little  fat.  Oat- 
meal is  rich  in  fat,  but  contains  less  starch  than  do 
the  other  grains.  It  has  almost  as  much  albumin- 
oid as  wheat  has.  When  not  sufficiently  cooked, 
it  is  irritating,  and  frequently  causes  digestive 
disturbances.  It  is  a  food  which  cannot  be  taken 
by  some  people,  though  the  number  is  not  large. 
Arrowroot,  tapioca,  and  sago  are  composed  almost 
entirely  of  starch.  They  are  readily  digested,  and 
are  especially  adapted  to  conditions  of  weak 
digestion.  Macaroni  consists  chiefly  of  gluten 
(nitrogenous  element),  with  a  small  proportion 
of   starch    and    fat.     When   plainly    cooked,    it    is 


REGIMEN    OF    ADULT    LIFE  353 

digestiVjle  and  nutritious.  With  a  large  amount 
of  butter  and  cheese  it  forms  a  very  complete 
and  rich  food,  but  is  digested  with  diiiticulty  by 
most  stomachs. 

The  potato  is  more  largely  used  in  this  country 
than  any  other  vegetable  food  except  wheat.  It 
contains  a  large  amount  of  starch.  It  is  quickly 
digested,  but  yields  considerable  amounts  of  vege- 
table acids.  It  is,  therefore,  more  liable  to  cause 
indigestion  and  flatulence  than  do  most  other 
starchy  foods.  The  vegetables  which  grow  under 
ground,  of  the  class  to  which  beets  and  turnips 
belong,  contain  a  large  proportion  of  starch.  They 
are  not  digested  as  easily  as  are  potatoes,  nor  are 
they  of  as  much  nutritive  value.  The  beet  con- 
tains sugar,  and  is  the  most  nutritious  member  of 
the  family.  The  group  of  vegetables  which  grow 
above  ground,  of  which  the  cabbage  is  a  type,  are 
valuable  additions  to  the  dietary,  although  their 
nutritive  value  is  not  great.  They  furnish  the 
bulk  and  residue  so  necessary  in  the  food,  but  are 
not  irritating  or  indigestible. 

Leguminous  plants  furnish  some  of  the  most 
valuable  of  foods.  Peas,  beans,  and  lentils  are 
the  most  important  members  of  this  group.  They 
contain  a  very  large  percentage  of  nitrogenous 
matter  combined  with  starch.     They  are  also  rich 


354  HOW    TO    KEEP    WELL 

in  organic  compounds,  especially  those  of  sulphur, 
phosphorus,  soda,  and  lime.  They  are  the  best 
substitutes  in  the  vegetable  kingdom  for  meat. 
Lentils  are  especially  rich  in  nitrogenous  matter 
and  starch.  They  are  among  the  most  valuable  of 
vegetable  foods,  and  are  worthy  of  more  general 
use.  Although  the  fruits  are  of  but  little  nutritive 
value,  they  are  important  articles  of  diet  owing  to 
their  antiscorbutic  properties  and  the  presence  of 
certain  vegetable  acids. 

Concentrated  food  is  a  fad  of  recent  years.  We 
sometimes  hear  the  prophecy  that  in  a  few  years 
we  shall  be  able  to  obtain  all  our  food  in  concen- 
trated or  compressed  form.  That  time  will  never 
come,  for  the  human  digestive  organs  were  not 
designed  for  such  use.  They  require  food  which 
produces  a  certain  amount  of  residue.  A  judicious 
mixture  of  concentrated  and  bulky  food  is  best. 
One  of  the  objections  to  an  exclusive  meat  diet 
is  its  concentration,  and  of  an  exclusive  vegetable 
diet  its  excessive  bulk.  The  modern  tendency  to 
seek  concentrated  food  is  shown  by  the  many 
nourishing  drinks  now  in  the  market.  "A  food 
to  drink"  is  not  a  good  thing  for  the  everyday  use 
of  the  average  individual.  There  are  certain  cir- 
cumstances in  which  a  concentrated  food  is  desir- 
able and  very  useful.     Water  is  one  of  the  impor- 


REGIMEN    OF   ADULT    LIFE  355 

tant  elements  of  the  diet.  It  is  the  solvent  of  the 
solids,  which  must  l^e  carried  out  of  the  body  to 
prevent  self-poisoning.  But  when  it  is  saturated 
with  solid  matter  it  cannot  take  up  more,  and  one 
of  its  most  important  offices  is  not  fulfilled.  The 
small  amount  of  solid  matter  in  tea  and  coffee  does 
not  materially  effect  its  action.  Milk,  it  should 
be  remembered,  though  a  liquid  outside  the  body, 
becomes  a  solid  upon  entering  the  stomach,  often 
a  very  tough  and  leathery  one.  It  is  a  rich  food, 
and  should  be  taken  as  such,  and  not  simply  as  a 
drink  with  meals.  The  concentrated  foods  have 
their  places,  and  are  invaluable  in  many  conditions 
of  modern  life,  but  it  is  a  mistake  to  make  of  them 
permanently  a  large  part  of  the  diet.  An  exclusive 
diet  of  uncooked  food  is  an  old  idea  recently 
revived.  It  is  unphysiological,  and  a  very  foolish 
fad. 

The  drinking  of  fluids  with  the  meals  is  objected 
to  by  most  writers  on  dietetics,  the  criticism 
usually  being  made  that  it  dilutes  the  gastric  juice 
and  thus  retards  digestion.  This  is  but  partially 
true.  The  excess  of  fluid  is  soon  absorbed,  if  the 
stomach  be  in  a  healthy  condition,  and  the  proper 
proportions  are  thus  maintained.  In  a  weak  and 
diluted  stomach,  however,  this  may  not  occur. 
The  chief  objection  to   drinking  at  meals  is  the 


356  HOW   TO    KEEP   WELL 

tendency  to  wash  down  the  food  without  sufficient 
mastication.  A  habit  which  most  people  can 
adopt  to  advantage  is  the  drinking  of  water  before 
breakfast.  It  is  best  to  take  it  as  hot  as  possible, 
and  to  sip  it  very  slowly.  If  it  is  lukewarm  it  may 
cause  nausea.  When  hot  water  is  not  available 
or  is  not  agreeable,  cold  water  may  be  taken.  It 
acts,  in  fact,  more  satisfactorily  with  some  indi- 
viduals than  does  hot  water.  This  morning 
draught  of  water  clears  the  mucus  from  the 
stomach  and  tones  it  up  to  its  work.  To  elderly 
people,  and  to  those  whom  George  Cheyne  would 
call  tender  persons  who  are  inclined  to  be  depressed 
and  chilly  in  the  morning,  the  draught  of  hot 
water  is  sometimes  very  comforting.  It  is  better 
than  tea  or  coffee,  though  there  is  little  objection  to 
them  at  that  time  if  they  are  taken  very  weak  and 
without  milk. 

For  many  people  the  importance  of  water  drink- 
ing is  very  great.  Those  who  are  stout  are  inclined 
to  be  large  water  drinkers,  and  for  them  the  amount 
must  often  be  restricted.  Many  who  require  it 
most,  on  the  other  hand,  are  inclined  to  be  small 
water  drinkers.  Those  who  are  subject  to  so- 
called  chronic  rheumatism,  uric  acid,  gout,  or 
kidney  troubles  should  make  it  a  rule  to  drink 
freely  of  water.     It  is  needed  to  dissolve  and  carry 


REGIMEN    OF    ADULT    LIFE  357 

out  of  the  system  various  poisonous  compounds 
resulting  from  tissue  waste.  Deficiency  of  water 
is  one  of  the  numerous  causes  of  constipation.  An 
increased  supply  will  sometimes  markedly  relieve 
that  troublesome  symptom,  particularly  if  taken 
freely  before  breakfast.  Cold  water  taken  in 
moderate  quantities  and  at  frequent  intervals 
during  the  day  not  only  acts  as  a  flush  to  the 
stomach  and  intestines,  but  tends  to  improve  the 
appetite.  It  also  stimulates  the  liver,  heart, 
kidneys,  and  skin  to  a  healthy  action.  Its  effect 
on  the  kidneys  is  not  only  to  increase  the  watery 
but  also  the  solid  constituents  of  their  secretion. 

A  few  words  may  be  said  regarding  two  com- 
monly used  articles  of,  diet — sugar  and  cereals. 
The  use  of  sugar  has  enormously  increased  during 
the  past  thirty  years.  It  is  the  common  impression 
that  it  is  not  properly  a  food,  but  a  deleterious  agent 
used  to  make  food  palatable,  which  by  habit  has 
become  a  necessary  evil.  This  is  a  great  error. 
Sugar  is  an  important  food  element  for  the  human 
animal.  While  cow's  milk  contains  but  four  per 
cent,  of  milk  sugar,  breast  milk,  designed  by  nature 
as  the  baby's  food,  contains  seven  per  cent.  This 
is  four  times  more  than  the  quantity  of  the  caseine, 
and  almost  twice  that  of  the  fat.  It  is  one  of  the 
fattening    elements    of   the    diet.     Artificially    fed 


358  HOW   TO    KEEP   WELL 

infants  who  are  deprived  of  an  adequate  quantity 
of  sugar  do  not  acquire  sufficient  fat.  In  the  adult 
body  it  is  one  of  the  most  efficient  producers  of  fat, 
as  well  as  a  generator  of  animal  heat  and  vital 
force.  It  is  a  valuable  food  for  labourers  and  those 
who  take  much  muscular  exercise.  This  fact  was 
appreciated  by  the  Government,  which  sent  espe- 
cially large  quantities  of  sugar  to  the  army  in  the 
Philippines  during  the  period  of  most  arduous 
labour.  The  chief  drawback  to  the  use  of  sugar 
is  its  tendency  to  cause  an  acid  fermentation  in 
the  stomach.  Taken  as  candy  between  meals,  it 
disturbs  the  digestion  and  impairs  the  appetite. 
Used  excessively  by  young  girls  and  boys,  it  is  apt 
to  be  a  generator  of  pimples.  Those  living  a 
sedentary  life  should  eat  much  less  of  it  than  those 
who  exercise  freely.  Moreover,  it  is  one  of  the  food 
elements  in  which  idiosyncracy  plays  an  active 
part.  It  does  not  agree  with  some  people.  They 
should  take  it  in  moderation,  and  not  be  too  critical 
of  those  who  can  take  it  more  freely.  It  scarcely 
needs  to  be  said  that  many  people  eat  too  much 
sugar,  while  enormous  quantities  of  candy  are 
given  to  children  which  they  would  be  far  better 
without. 

Methods  of  cooking  have  a  great  influence  in 
rendering  food  wholesome.     This  is  markedly  so 


REGIMEN    OF    ADULT    LIFE  359 

with  cereals.  By  proper  cooking  and  a  little 
training  in  their  use  there  are  few  people  who  can- 
not make  them  an  element  of  their  dietary,  and  a 
very  valuable  one.  They  have  been  brought  into 
disrepute  in  many  families  by  the  use  of  the  so- 
called  cooked  cereals,  which  are  alleged  to  require 
little  more  than  heating  to  render  them  ready  foi 
use.  Half-cooked  cereals  are  a  common  source 
of  intestinal  indigestion.  This  is  particularly  true 
of  oatmeal,  which  requires  prolonged  cooking 
(rarely  less  than  six  hours),  and  steam-cooked 
requires  almost  as  long  as  does  the  uncooked.  It 
cannot  be  properly  cooked  in  the  morning  before 
breakfast.  What  is  to  be  served  in  the  morning 
should  be  put  on  the  range  in  the  evening,  in  a 
double  boiler,  with  plenty  of  water,  and  allowed  to 
cook  slowly  all  night. 

Many  wholesome  articles  of  diet  are  rendered 
indigestible  by  the  usual  methods  of  cooking. 
Mushrooms,  for  instance,  are  among  the  most 
nutritious  articles  at  our  command,  but  the  man- 
ner in  which  they  are  usually  cooked  renders  them 
difficult  of  digestion.  Lobster  has  acquired  a 
much  worse  reputation  than  it  deserves  because 
of  the  abominable  combinations  in  which  it  is 
frequently  served.  The  process  of  frying  per- 
meates the  food  with  fat.     Fat  is  not  digested  in 


36o  HOW   TO    KEEP    WELL 

the  stomach.  Hence,  in  fried  food  the  gastric  juice 
cannot  reach  the  albuminoids  and  connective 
tissues,  and  they  pass  from  the  stomach  undigested, 
to  cause  intestinal  indigestion. 

The  tea  and  coffee  question  is  another  subject 
upon  which  extreme  views  are  held.  As  is  the 
case  with  all  articles  of  their  class,  the  element  of 
personal  peculiarity  is  very  prominent,  and  people 
are  inclined  to  draw  positive  conclusions  from  their 
own  experience.  Coffee  will  cure  a  headache  in 
one  and  cause  it  in  another.  Tea  will  keep  one 
person  awake  and  help  another  to  sleep.  Every 
rule  regarding  their  use  is  subject  to  the  question 
of  personal  idiosyncracy.  Out  of  all  the  turmoil, 
there  is  no  adequate  evidence  to  show  that  the 
moderate  use  of  tea  and  coffee  does  most  individ- 
uals harm.  The  term  moderate  use  is  difficult  to 
define,  but  it  does  not  mean  three  times  a  day  for 
sedentary  workers.  When  taken  strong  in  large 
quantities  at  every  meal  or  between  meals,  they 
may  be  very  injurious.  To  take  them  in  place  of 
food,  or  to  keep  up  one's  strength  and  nerve  power, 
is  the  height  of  folly.  Tea  steeped  till  it  is  black 
with  tannin  and  extractives,  and  taken  in  large 
amounts,  is  capable  of  causing  one  of  the  worst 
forms  of  acid  dyspepsia.  It  is  the  cause  of  much 
of  the   dyspepsia  of  American   servant   girls,   and 


REGIMEN    OF   ADULT    LIFE  361 

dyspepsia  is  indigenous  to  them.  It  is  one  of  the 
underlying  causes  of  the  "servant  question."  The 
strong  young  girl,  accustomed  to  a  simple  life  and 
plain  diet,  who  has  rarely  been  ill,  comes  to  America 
and  enters  domestic  service.  Within  a  few  months 
she  almost  invariably  becomes  anemic  and  devel- 
ops dyspepsia.  Tea  is  one  of  the  chief  causes. 
Other  contributing  causes  are  unwonted  confine- 
ment to  the  house  and  eating  the  richest  and  most 
indigestiljle  portions  of  the  diet  which  the  kitchen 
affords.  This,  with  frequent  draughts  of  tea  which 
stands  on  the  back  of  the  range  all  day,  is  adequate 
explanation  for  the  prevailing  dyspepsia  of  servants, 
and,  as  a  corollary,  many  of  the  woes  of  modern 
housekeeping.  It  is  a  subject  worthy  of  the 
attention  of  some  of  the  good  people  interested  in 
improving  the  condition  of  domestics.  Many  of 
these  foreign-born  domestics  present  some  of  the 
most  picturesque  examples  of  dyspepsia,  "the 
American  disease." 

Coffee  diminishes  tissue  waste  and  thus  tem- 
porarily renders  a  less  amount  of  food  necessar}^ 
but  is  itself  in  no  sense  a  food.  It  is,  therefore, 
clogging  in  its  action.  This  may  be  very  desirable 
in  those  engaged  in  active  muscular  labour  in  whom 
tissue  waste  is  very  rapid.  It  is  manifestly  less 
desirable  in  those  of  sluggish  habit  or  sedentary 


362  HOAV    TO    KEEP   WELL 

occupation.  Even  more  than  in  the  case  of  meat 
and  sugar,  the  use  of  coffee  should  be  graduated 
according  to  the  amount  of  physical  exercise  taken. 
The  action  of  tea  in  the  system  is  quite  complex, 
but  it  does  not  diminish  tissue  waste  to  the  extent 
that  coffee   does. 

In  referring  to  a  tendency  of  those  who  have 
found  some  particular  combination  of  nourish- 
nient  suited  to  their  own  stomachs  to  infer  that  it 
will  be  equally  acceptable  to  the  stomachs  of  their 
neighbours,  Sir  Henry  Thompson  asserts  that  it 
would  be  no  more  preposterous  to  assume  that  a 
shoe  adapted  to  one's  own  foot  will  be  equally 
adapted  to  those  of  one's  neighbours.  Feet  prob-  * 
ably  do  not  differ  more  than  do  digestive  organs. 
But  it  is  possible  even  in  the  matter  of  shoes 
to  lay  down  some  general  rules.  For  mountain 
climbing,  thick-soled  tans  may  be  worn;  with 
evening  dress,  thin  patent  leathers.  While 
shoes  may  be  light  and  thin  in  summer, 
they  should  be  heavier  and  thicker  in  winter. 
The  exact  style  and  finish,  however,  may  differ 
with  each  individual.  And  so  in  diet  we 
may  lay  down  certain  general  rules,  leaving 
the  details  to  be  modified  by  each  person 
applying   them : 

The    diet    of   an    ordinarv    individual    in    health 


REGIMEN    OF    ADULT    LIFE  363 

should  contain  a  variety,  not  one  of  the  great  food 
staples   being   excluded. 

Its  character  should  vary  with  age,  climate, 
season,  and  occupation,  no  one  system  of  diet 
being  adapted  to  the  needs  of  all. 

After  the  period  of  growth  has  passed,  and  full 
development  has  been  reached,  the  amount  of 
aliment  should  be  diminished  rather  than  increased. 

The  diet  of  hot  weather  should  be  lighter  in 
quality  and  less  in  quantity  than  that  of  cold 
weather. 

The  amount  of  physical  exercise  taken  should  be 
the  chief  guide  in  determining  the  quantity  of  the 
heartier  food  consumed,  particularly  meat,  fat, 
sugar,  and  coffee.  The  more  the  muscular  exer- 
cise the  more  the  food.  Active  brain  workers, 
however,  require  more  of  these  foods  than  do  those 
of  similar  habits  who  do  not  undergo  mental 
exertion. 

It  is  neither  necessary  nor  wise  to  habitually 
leave  the  table  hungry,  neither  is  it  wise  to  "eat 
so  much  as  will  indispose  for  business.  "  Let  your 
moderation  be  known  unto  all  men.  It  will 
neither  diminish  your  own  happiness  nor  impair 
your  reputation. 


CHAPTER   XIV 

The  Dangers  of  Middle  Life 

In  a  previous  chapter  attention  was  called  to  the 
fact  that  the  expectation  of  life  of  the  infant  born 
to-day  is  greater  than  was  that  of  the  infant  born 
fifty  years  ago,  while  that  of  the  average  man  of 
middle  age  is  not  so  great.  It  is  the  object  of  this 
chapter  to  seek  the  reason  for  this  startling  fact, 
and,  if  possible,  to  suggest  remedies.  Some  of 
these  reasons  have  already  been  touched  upon, 
but  will  be  here  considered  at  greater  length.  It 
has  been  suggested  that  the  great  saving  in  child 
life  made  in  recent  years  has  resulted  in  carrying 
into  adult  life  many  weaklings,  who  are  unable  to 
sustain  the  burden  when  the  retrograde  changes  of 
middle  life  begin  to  appear.  There  is,  no  doubt, 
some  truth  in  this,  but  not  very  much.  The 
diseases  of  infancy  are  such  that  many  perfectly 
healthy  children  are  stricken  and  do  not  recover. 
The  saving  in  child  life  has  by  no  means  been 
among  the  weaklings  alone.  We  must  look  further 
for  reasons  if  we  would  avoid  error. 

364 


THE    DANGERS    OF    MIDDLE    LIFE  365 

It  seems  improbable  that  this  reduction  of  life 
expectation  would  occur  equally  among  all  sorts 
and  conditions  of  men.  And  this  we  find  to  be  the 
fact.  It  is  most  marked  in  some  of  the  classes 
outside  of  the  so-called  labouring  class.  While 
not  confined  to  cities,  it  is  more  apparent  in  them 
than  in  the  country.  It  would  be  manifestly 
impossible  to  offer  advice  that  would  be  equally 
applicable  to  every  grade  of  the  social  scale.  We 
must  therefore  eliminate  certain  elements.  There 
is  little  satisfaction  in  shooting  at  too  large  a 
target.  We  will,  in  the  present  chapter,  eliminate 
the  "working-man" — a  ver}^  bad  expression,  for  it 
seems  to  imply  that  labour  and  toil  is  not  work 
unless  performed  by  the  hands.  This  class  of 
toilers  is  free  from  some  of  the  conditions  which 
shorten  life  in  others.  Moreover,  "organized 
labour"  has  a  very  lively  appreciation  of  its  own 
personal  interests.  It  is  striking  in  season  and 
out  of  season  for  better  pay,  better  conditions,  and 
shorter  hours  of  labour.  It  is  the  employer  who 
particularly  needs  instruction  as  to  how  to  take 
care  of  himself. 

The  sins  of  modern  society  are  often  attributed 
to  the  mad  struggle  for  wealth  and  power.  There 
is  such  a  struggle  past  all  denying,  but  it  is  an 
exaggeration  to  attribute  ever3^thing  to  it.     Where 


366  HOW   TO    KEEP   WELL 

one  man  is  madly  struggling  for  wealth  and  power, 
ten  are  labouring  for  a  competence  and  a  hundred 
are  contending  for  sheer  existence.  Modern  society 
has  not  been  made  what  it  is  by  any  single  class, 
but  is  the  result  of  many  complex  forces.  No 
individual  and  no  class  can  materially  change  it 
or  stem  the  current.  Most  men  and  women  are 
thrown  into  that  current  through  no  volition  of 
their  own,  and  existence  is  a  struggle  to  keep  afloat. 
It  is  the  comparatively  few  who,  by  special  ability 
and  tmremitting  effort,  can  radically  change  their 
condition  in  life.  But  the  attempt  to  do  so  is  not 
a  crime.  The  strenuous  life  is  not  a  sin.  It 
becomes  so  only  when  it  degenerates  into  a  fierce 
struggle  for  wealth  that  is  not  required,  or  for 
power  that  is  sought  only  for  self-aggrandizement. 
Those  engaged  in  such  a  struggle  we  will  eliminate, 
also,  from  consideration  in  this  chapter.  The 
only  advice  to  be  given  to  such  is  to  stop  it  and 
begin  the  living  of  a  sane  and  reasonable  life.  AVe 
will  eliminate  also  the  body  of  men,  small  in  this 
country,  knov/n  as  the  leisure  class.  No  advice 
that  could  here  be  given  would  induce  them  to 
materially  change  their  mode  of  life. 

There  are  great  bodies  of  men,  particularly  in 
the  larger  towns,  who  from  choice  or  necessity  lead 
the  strenuous  life  in  all  that  that  expressive  term 


THE    DANGERS    OF    MIDDLE    LIFE  367 

implies.  By  common  acceptance,  this  term  applies 
as  much  to  the  mental  worker  as  to  the  physical 
labourer.  These  toilers  include  the  literary,  pro- 
fessional, and  business  men  of  all  classes — all  those, 
in  fact,  who  labour  with  body  and  brain  and  are 
heavy  laden  with  responsibilities.  This  adding  of 
responsibility  to  labour  is  a  combination  of  condi- 
tions which  gathers  individuals  of  widely  differing 
occupations  into  one  great  group  having,  from  the 
point  of  view  of  the  physician,  many  elements  in 
common.  It  is  quite  true  that  every  individual, 
except  the  tramp,  has  certain  responsibilities  per- 
taining to  his  own  welfare  and  that  of  his  family. 
But  beyond  this,  which  may  be  called  personal 
responsibilit3^  there  is  a  steadily  increasing  number 
of  people  in  the  communit}^  whose  daily  duties 
consist  in  the  bearing  of  great  burdens  of  care. 
The  proprietor  of  the  little  general  store  in  the 
country  village  has  his  cares  and  perplexities,  but 
they  are  scarcely  to  be  compared  with  the  responsi- 
bilities resting  upon  the  shoulders  of  those  who 
manage  a  great  city  department  store  with  its 
several  thousand  employees.  The  active  members 
and  higher  employees  of  every  business  firm  and 
corporation  have,  in  addition  to  their  hours  of 
labour,  heavy  burdens  of  responsibility.  There  is 
perpetual   planning,  devising,  and   negotiating   to 


368  HOW   TO    KEEP   WELL 

keep  abreast  of  competitors.  As  great  weariness 
comes  from  mental  as  from  physical  labour.  When 
the  two  are  combined  and  upon  all  are  laid  responsi- 
bility and  accountability  to  others,  the  burden 
becomes  enormous. 

Not  only  has  the  number  of  men  occupying 
responsible  positions  increased,  but  the  responsi- 
bilities themselves  have  vastly  grown  with  the 
increase  in  the  volume  of  the  business.  The  vast 
business  enterprises  of  to-day  entail  vast  burdens 
of  care  upon  some  one.  Compare  the  responsi- 
bilities of  the  national  administration  of  1800, 
which  presided  over  a  little  country  of  5,000,000 
inhabitants  located  along  the  Atlantic  seaboard, 
with  those  of  the  administration  of  1900,  which 
has  in  its  keeping  the  destiny  of  76,000,000  people 
spreading  out  between  the  Atlantic  and  the  Pacific 
and  reaching  across  seas  to  take  control  of  10,000,000 
or  12,000,000  more.  The  difference  in  the  nation, 
however,  is  not  greater  than  is  the  difference  in 
most  kinds  of  business.  Compare  the  financial 
transactions  of  the  banks  of  but  fifty  years  ago 
with  those  of  to-day,  and  remember  that,  with 
each  increment  of  business,  there  is  an  increase  in 
labour  and  responsibility  for  every  one  of  the 
higher  officials.  Compare  the  newspaper  of  to-day 
with  that  of  the  early  nineteenth  century.     Many 


THE    DANGERS    OF    MIDDLE    LIFE  369 

an  American  town  of  50,000  inhabitants  now 
supports  a  larger  paper,  and  one  involving  more 
business  enterprise,  than  did  any  metropolis  of  a 
century  ago.  Compare  the  little  factories  of  1850 
with  the  vast  manufacturing  establishments  of 
to-day.  One  industry  alone  is  capitalized  at  more 
than  $1,000,000,000,  while  our  total  exports  have 
almost  trebled  since  1875.  These  examples  might 
be  multiplied  by  the  score. 

All  this  brings  us  back  to  the  one  word  repeated 
so  many  times  in  the  last  few  paragraphs,  because 
there  is  none  other  which  expresses  the  idea — 
responsibility.  The  vast  increase  in  every  variety 
of  business  means  an  increase  in  the  number  of 
men  bearing  responsibility  and  in  the  weight  of 
the  burdens  carried. 

It  is  another  peculiar  feature  of  this  modern 
life  that  these  burdens  of  responsibility  are  rarely 
borne  for  the  individual  alone.  They  are  carried 
for  others,  for  almost  every  man  is  accountable  to 
some  one.  The  president  of  the  bank  or  corpora- 
tion may  be  satisfied  that  he  has  done  the  best 
that  he  could  have  done  under  the  circuinstances , 
but  the  question  is  always  in  his  mind  whether  his 
directors  will  also  be  satisfied.  The  employer 
considers  his  employees,  who  are  dependent  upon 
the  success  of  his  business  for  their  dailv  bread  as 


370  HOW   TO    KEEP   WELL 

is   his   own   family.     The   agent,   the   broker,   the 
manager,     the     superintendent,     the     editor,     the 
publisher,    the    corporation    official,    are    all    doing 
more  or  less  the  work  of  others,  and  are  accountable 
to  others  legally  or  morally.     This  is  particularly 
true    of   the   professional    classes.     Their   work   is 
almost  exclusively  done  for  others,  and  they  are 
answerable  to  others  for  every  act.     The  work  of 
the  lawyer  and  the  doctor  must  be  satisfactory  to 
their    clients    and    patients.     This    is    the    feature 
of  the  daily  life  of  each  which  renders  their  labours 
so   trying   upon  the  nerves.     Their  responsibility^ 
as  well  as  that  of  the  business  man,  has  increased. 
The  great  man  of  the  legal  profession  of  old,  the 
criminal   lawyer,    had   but   little   responsibility    as 
compared  with  his  brother  of  to-day,  who  is  the 
legal  adviser  of  great   corporations   and   business 
houses  and  has  the  administering  of  vast  estates. 
The    responsibility    of    the    old-time    doctor    was 
also  less  than  that  of  the  physician  or  surgeon  of 
to-day,    of    whom    so    much    is    expected.     These 
various  men  of  responsibility  cannot  die,  or  even 
take  a  necessary  vacation,  without  seriously  dis- 
commoding others  or  deranging  the  affairs  of  their 
fellow  men.     Never  in  the  history  of  the  world 
has  that  Biblical  expression  been  so  true  as  it  is 
to-day  of  this  army  of  responsible  men  and  women : 


THE    DANGERS    OF    MIDDLE    LIFE  371 

"For  none  of  us  liveth  to  himself,  and  no  man 
dieth  to  himself." 

The  second  factor  tending  to  shorten  the  career 
of  men  in  active  life  is  the  high  tension  under  which 
their  work  is  performed.  This  is  a  high -pressure 
age,  not  so  much  from  the  choice  of  the  people  as 
from  necessity.  As  the  volume  of  business  has 
increased,  the  hours  have  not  lengthened  them- 
selves to  permit  its  being  done  in  the  old  leisurely 
manner.  It  must  be  done  in  a  hurry  or  a  part  of 
it  will  be  left  undone.  The  telegraph,  the  sub- 
marine cable,  and  the  telephone  have  increased 
rather  than  diminished  the  tension  of  business  life. 
When  it  required  two  days  for  the  business  man  in 
Xew  York  to  get  a  reply  to  his  Philadelphia  letter, 
he  was  obliged  to  be  deliberate.  Xow  he  sits  at 
his  desk  and  completes  his  deal  in  Philadelphia 
by  telephone.  He  does  almost  a  full  day's  work  in 
Xew  York  on  Monday,  goes  to  Chicago,  transacts 
three  hour's  business  on  Tuesday,  and  returns  to 
Xew  York  in  time  for  the  opening  of  business  on 
Wednesday  morning.  He  completes  a  half-dozen 
transactions  now  where  he  completed  one  fifty 
years  ago.  Of  course,  he  does  it  under  high 
pressure. 

The  old-time  merchant,  who  has  been  admirably 
described     in     several     recent     historical     novels, 


372  HOW    TO    KEEP    WELL 

loaded  his  ships  and  sent  them  across  seas  and 
calmly  awaited  their  return  several  months  later. 
He  could  not  hurry  nor  live  at  a  very  high  pressure 
if  he  tried.  Opposite  this  picture  set  the  modern 
importer  in  telegraphic  communication  with  the 
uttermost  parts  of  the  earth,  whose  invoices  are 
arriving  by  every  week's  steamers.  His  lot  is 
cast  with  those  who  "hurry  to  and  fro  and  strive 
unceasingly."  If  he  does  not  do  the  same  he  will 
be  left  behind  and  his  business  will  fail.  Thus 
another  is  added  to  the  striving  throng  and  adds 
to  the  rush  and  hurry.  The  "gentleman  of  the 
old  school,"  with  his  elaborate  courtesy,  his  stately 
bearing,  and  deliberate  ways,  is  almost  an  impos- 
sibility under  modern  conditions,  the  more's  the 
pity.  It  is  doubtful,  however,  whether  there  are 
fewer  gentlemen  now  than  there  were  a  century 
ago,  though  they  appear  under  different  guise. 

A  third  reason  for  the  condition  we  are  consider- 
ing is  the  tendency  to  concentration  of  the  popula- 
tion in  urban  communities.  Overcrowding  is  not 
conducive  to  health,  even  for  those  who  live  in  the 
better  localities.  Still,  it  must  be  said  that  for 
those  who  can  live  in  such  localities  during  the 
cold  months,  and  spend  a  liberal  part  of  the  hot 
season  in  the  country,  the  conditions  of  home  life 
are  not  bad.     They  are  usually  better  than  are 


THE    DANGERS    OF    MIDDLE    LIFE  373 

the  hygienic  conditions  where  the  business  is 
done.  But,  unfortunately,  very  few  business  men 
can  spend  a  large  part  of  the  warm  season  out  of 
town.  Many  of  them  pass  the  most  trying  part  of 
the  year  in  a  dismantled  house,  deprived  of  many 
of  the  comforts  of  home.  In  many  cases  it  is 
impossible  to  obviate  this,  particularly  when  there 
are  young  children  in  the  family.  This  summer 
life  of  city  men  is  unfortunate  from  every  point  of 
view,  and  is  particularly  so  for  those  who  have 
reached  or  passed  middle  life.  Even  were  the 
hygienic  conditions  of  the  home  life  and  business 
always  perfect,  in  the  rush  and  roar  of  great  num- 
bers there  is  a  nervous  strain  that  has  a  decided 
influence  upon  the  health,  though  it  may  not  be 
perceived  at  the  time. 

A  fourth  reason  is  the  sedentary  life,  which 
claims  scores  of  thousands  of  modern  toilers. 
It  is  a  subject  of  sufficient  importance  to  warrant 
consideration  in  a  subsequent  chapter. 

A  fifth,  and  in  some  cases  a  very  important, 
cause  of  breakdown  or  shortened  life  is  bad  methods 
of  living,  or  actual  dissipation.  The  overuse  of 
alcohol  and  tobacco,  vicious  diet,  and  sensuality 
have  wrecked  many  a  promising  career.  These 
things,  in  conjunction  with  one  or  more  of  the 
preceding    causes,    largely    explain    the    reduced 


3  74  HOW   TO    KEEP   WELL 

expectation  of  life  of  middle-aged  men  of  the 
present  day.  These  causes  do  not  usually  begin 
in  middle  life,  but  the  results  of  the  wrong  living 
in  earlier  years  become  manifest  at  this  period. 
One  of  the  greatest  mistakes  a  man  ever  makes  is 
to  do  his  work  on  stimulants.  If  he  cannot  do  his 
work  this  year  without  artificial  strength,  does  he 
expect  he  can  do  it  next  year?  If  he  has  not 
sufficient  strength  to  do  his  work  at  thirty,  what 
does  he  expect  to  do  at  forty  or  fifty,  when  his 
business  will  naturally  be  larger  and  more  exacting  ? 
Does  he  expect  to  grow  stronger  as  years  are  added 
to  his  age  ?  This  daily  bracing  up  with  stimulants, 
so  common  among  young  business  and  professional 
men,  is  sheer  insanity.  If  a  man  is  not  strong 
enough  to  do  his  work,  he  ought  to  reduce  it,  or, 
if  that  is  impossible,  stop  it,  and  do  something 
else  at  any  sacrifice.  Working  on  stimulants  will 
lead  to  disaster,  mental  and  physical.  If  it  is 
persisted  in  there  is  no  way  under  heaven  given 
among  men  whereby  a  man  may  be  saved.  His 
career  will  end  in  failure  and  sorrow. 

A  prominent  New  York  newspaper  has  recently 
asserted  that  it  is  the  recreations  of  modern  busi- 
ness men  which  kill,  rather  than  their  work.  There 
are  both  truth  and  exaggeration  in  this  statement. 
Many  men  are  killed  by  their  recreations,  in  addi- 


THE    DANGERS    OF    MIDDLE    LIFE  375 

tion  to  their  work.  The  Vjreakdown  of  a  very  promi- 
nent man  of  affairs  has  recently  been  an  example  in 
proof  of  this  statement .  "It  has  long  been  evident , ' ' 
says  the  New  York  Times,  in  referring  to  this 
case,  "that  he  was  maintaining  the  pace  that  kills. 
Driving  an  automobile  at  record  speed,  risking 
large  stakes,  and  making  large  winnings  at  Monte 
Carlo,  sitting  up  all  night  and  coming  to  his  desk 
unrest ed  and  unrefreshed  in  the  morning,  dashing 
here  and  there  in  special  trains  to  save  time,  and 
meanwhile  keeping  his  hands  on  the  levers  which 
control  a  manufacturing  business  of  unparal- 
leled magnitude,  he  has  not  only  burned  his  candle 
at  both  ends,  but  in  the  middle  as  well."  If ,  in 
addition  to  the  rush,  strain,  and  responsibility  of 
modern  business  life,  a  man  makes  his  recreations 
more  exhausting  than  his  work,  he  must  expect  to 
leave  them  at  an  early  age.  Breakdown  is  the 
only  possible  result. 

These  conditions  (an  excessive  burden  of  responsi- 
bility, high  tension  of  labour,  overcrowding  of 
population,  the  sedentary  life,  erroneous  methods 
of  living,  and  exhausting  recreations)  account 
largely  for  the  ill-health  and  breaking  down  of 
modern  business  and  professional  men. 

There  is  another  cause,  not  universal,  but  of 
sufficient  importance  to  merit  consideration.     This 


376  HOW    TO    KEEP   WELL 

is  a  tendency  all  along  the  social  line  to  remove 
from  a  comparatively  quiet  to  a  comparatively 
exciting  life.  The  farmer  removes  into  the  village; 
the  successful  business  man  of  the  village  removes 
to  the  large  town  or  city ;  the  successful  man  of  the 
city  has  an  ambition  to  complete  his  career  in  the 
metropolis.  In  each  case  the  new  life  is  strange 
and  untried,  and  is  lived  at  a  higher  tension  than 
was  the  old.  Such  changes  made  in  middle  life 
are  the  cause  of  many  disasters,  both  financial  and 
physical.  It  seems  impossible  for  many  men  to 
understand  that  success  in  one  place  does  not 
necessarily  fit  them  to  cope  with  the  conditions 
present  in  another,  and  they  enter  the  new  life 
unprepared  for  its  conditions.  They  might  well 
learn  wisdom  from  a  precaution  which  railroad 
managers  adopt  when  they  make  a  radical  change 
in  the  rate  of  running  trains,  as  in  the  new  twenty- 
hour  trains  between  New  York  and  Chicago. 
They  give  the  engineer  an  expert  assistant  known 
as  the  traveling  engineer.  "The  running  of  a  fast 
locomotive  requires  not  only  skill,  but  also  nerve, 
and  the  duty  of  the  traveling  engineer  is  to  sustain 
the  running  engineer  in  the  nerve-trying  swift 
runs,  until  he  has  become  accustomed  to  the  swift 
schedule."  If  every  man  who  has  an  itching  to 
commit  himself  and  all  his  fortunes  to  a  new  and 


THE    DANGERS    OF    MIDDLE    LIFE  377 

more  rapid  career  than  the  one  to  which  he  is 
accustomed  would  take  precautions  to  prepare 
himself  for  such  a  new  life,  there  would  be  fewer 
smash-ups. 

Gambling,  which  is  much  more  common  than 
many  people  suppose,  is  a  potent  cause  of  break- 
down and  disaster.  The  same  is  true  of  stock 
speculation  and  those  forms  of  business  which 
possess  a  gambling  element.  The  suspense  and 
anxiety  not  only  keep  the  mind  at  a  dangerous 
tension,  but  bring  into  play  some  of  the  worst 
passions  of  human  nature.  The  man  who  elimi- 
nates as  far  as  it  is  possible  the  element  of  chance 
from  his  business  has  done  much  to  insure  length 
of  years  as  well  as  happiness  and  peace  of  mind. 
The  gambling  feature  in  many  kinds  of  modern 
business  is  an  appreciable  cause  of  breakdown  at 
middle  life. 

The  results  produced  by  these  various  conditions 
are  chiefly  the  following:  general  nervous  break- 
down (often  known  as  neurasthenia,  nervous  pros- 
tration, or  business  man's  breakdown)  and  organic 
diseases,  the  chief  of  which  are  Bright 's  disease, 
gout,  uric  acid  tendency,  diseases  of  the  liver  or 
digestive  organs,  and  degeneration  of  the  arteries. 
These  conditions  rarely  develop  without  premoni- 
tions,    A  red  light  is  usually  thrown  out  to  give 


378  HOW   TO    KEEP   WELL 

warning  that  there  is  danger  ahead.  It  is  an 
unwise  man  who  runs  by  them  one  after  the  other 
without  slackening  speed.  Every  man  ought  to 
understand,  that  when  he  has  reached  the  age  of 
forty-five  he  has  entered  upon  a  period  of  hfe  in 
which  certain  accidents  are  common.  They  are 
not  inevitable,  and  he  will  be  unwise  to  allow  him- 
self to  become  morbid  upon  the  subject,  and  be 
worried  by  a  dread  of  what  ma}^  never  come.  He 
ought,  however,  to  recognize  the  fact  that  this 
period,  like  every  other  stage  of  life,  has  its  par- 
ticular dangers,  and  not  run  blindly  into  them. 
Although  he  feels  and  looks  young,  he  should  not 
forget  that  he  is  a  "middle-aged  man." 

Certain  retrograde  changes  begin  about  that 
time  of  life,  and  the  fact  should  not  be  ignored. 
The  time  at  which  these  changes  begin  varies 
greatly  in  different  individuals  and  in  different 
families.  It  depends  much  upon  the  earlier  life 
and  inherited  tendency.  In  most  men  of  fifty, 
who  have  lived  an  intense  life  with  its  cares  and 
responsibilities,  in  some  of  the  organs  there  is  what 
Doctor  Holmes  would  call  "a  general  flavour  of 
mild  decay."  It  may  be  simply  a  flavour,  very 
general  and  very  mild,  but  still  the  word  decay 
must  be  spoken.  We  are  unfortunately  not  built 
upon  the  plan  of  the  "One  Hoss  Shay,"  which  had 


THE    DANGERS    OF    MIDDLE    LIFE  379 

no  weakest  spot,  but  ran  a  hundred  years  to  a  day 
and  then  collapsed  in  a  most  becoming  manner 
and  in  an  appropriate  place.  We  all  have  our 
weakest  spot,  and  we  are  no  stronger  than  that 
spot,  as  a  chain  is  not  stronger  than  its  weakest 
link.  The  insurance  examiner  is  frequently  the 
first  to  detect  it.  It  may  be  indicated  only  by  a 
little  albumin  or  sugar  in  the  urine,  an  abnormal 
sound  in  the  heart  beat,  or  a  peculiar  quality  in 
the  pulse.  Such  things  are  sufficient  for  rejection 
by  the  company,  but  in  a  large  number  of  cases 
never  cause  any  serious  trouble,  provided  the 
individual  takes  warning  and  begins  to  live  a  more 
rational  life.  Many  a  man  is  living  in  health 
to-day  who  was  rejected  upon  adequate  grounds 
by  an  insurance  company  twenty  years  or  more 
ago.  These  various  organic  diseases  will  be  con- 
sidered in  detail  in  a  following  chapter. 

General  nervous  breakdown,  like  the  organic 
diseases,  usually  shows  its  danger  signals  some  time 
in  advance.  Persistent  insomnia  in  one  who  has 
been  a  good  sleeper,  unwonted  irritability,  worry 
over  details  of  business,  loss  of  power  of  concentra- 
tion, prolonged  lack  of  energy,  and  a  dread  of 
grappling  with  business  problems,  are  warning 
signals.  Occurring  for  limited  periods,  they  mean 
Httle  or  nothing,  and  ma}^  depend  upon  some  tern- 


38o  HOW   TO   KEEP   WELL 

porary  ailment.  Any  one  or  two  alone  may  indi- 
cate little.  Their  importance  may  be  easily 
exaggerated  and  cause  unnecessary  alarm.  But 
several  of  them  occurring  in  conjunction  and  per- 
sisting are  danger  signals  which  should  not  be 
ignored. 

That  breakdown  is  not  a  necessary  result  of 
modern  conditions  is  proved  by  the  fact  that  many 
men  are  to-day  filling  most  responsible  positions 
without  ph3^sical  or  mental  impairment,  while 
others  who  have  lived  the  strenuous  life  in  its  best 
sense  have  reached  a  hale  and  vigorous  old  age. 
Moderation  and  temperance  in  all  things,  a  judi- 
cious regimen,  regular  hours  and  sufficient  sleep, 
adequate  exercise,  and  wholesome  recreations  will 
enable  a  normal  man  to  bear  in  safety  the  burden 
and  responsibilities  which  the  most  exacting  modern 
business  imposes. 


CHAPTER   XV 

The    Prevention    of   Breakdown 

Some  of  the  conditions  discussed  in  the  preced- 
ing chapter  cannot  be  cured,  and  must  be  endured. 
Overcrowding  of  the  population  must  be  tolerated 
by  most  men  whose  place  of  breadwinning  is  in 
the  city.  The  suburbs,  to  be  sure,  are  available, 
but  residence  there  is  largely  a  question  of  personal 
choice.  Suburban  life  is  agreeable  to  some  and 
distasteful  to  others.  It  is  adopted  oftentimes 
because  a  country  life  is  deemed  best  for  the 
children.  It  is  frequently  a  serious  question  to 
what  extent  the  health  and  comfort  of  the  father 
should  be  sacrificed  for  the  sake  of  the  children. 

Responsibility  and  high  tension  of  life  cannot  be 
escaped  by  him  who  lives  intensely  and  aids  in 
carrying  on  the  business  of  the  world.  Much, 
however,  may  be  done  in  many  cases  to  reduce 
these  burdens  as  age  advances.  Upon  the  first 
indication  of  failing  powers,  either  mental  or 
physical,  the  burden,  as  far  as  it  is  possible,  should 
be  lightened.     One  of  the  first  means  of  attaining 

381 


382  HOW    TO    KEEP   WELL 

this  end  is  by  cutting  off  the  more  distant  and  least 
manageable  portions  of  the  business.  As  far  as 
possible,  the  business  should  be  brought  within 
sight  and  reach.  It  is  the  outlying  portions 
which  are  beyond  personal  supervision  that  cause 
the  most  worry.  Cut  them  off  and  make  the 
business  more  compact  and  manageable.  Do  not 
keep  too  many  irons  in  the  fire.  The  watching  of 
each  additional  one  demands  additional  concen- 
tration, and  adds  to  the  mental  tension.  Work 
one  or  two  fields  well  and  obtain  all  they  will  yield, 
rather  than  half  a  dozen  superficially;  it  will  be 
far  easier;  you  will  live  longer  and  accumulate  as 
much  in  the  end.  "The  one  prudence  in  life  is 
concentration;  the  one  evil  is  dissipation."  Many 
a  man  has  dissipated  his  vital  and  mental  powers 
by  attempting  to  spread  them  over  too  much 
surface.  Study  your  own  capabilities;  be  honest 
with  yourself;  if  you  are  convinced  that  you  have 
large  business  capabilities,  do  not  over-restrict 
them.  But  do  not  make  radical  changes,  nor 
undertake  entirely  new  kinds  of  business  after 
middle  life.  You  may  not  fail ;  but  success  will 
be  purchased  at  too  great  an  expenditure  of  vital 
and  nervous  force. 

Many  Americans  maintain  a  higher  tension  of 
life  than  is  necessary.     The  delirious  style  of  doing 


THE  PREVENTION  OF  BREAKDOWN  383 

busineSvS  is  partly  habit,  and  in  some  cases  is  done 
for  effect.  Men  often  keep  themselves  in  a  nervous 
state  and  do  more  rushing  about  than  there  is  any 
necessity  for.  They  keep  themselves  keyed  up  to 
such  a  pitch  that  they  use  up  as  much  vital  force 
in  doing  routine  work  and  unimportant  details 
as  in  negotiating  great  transactions.  Like  the 
yellow  journals  which  print  enormous  headlines 
for  the  most  trivial  matters,  and  work  themselves 
into  an  excitement  over  commonplace  events,  they 
give  undue  importance  to  details,  and  do  every- 
thing at  high  pressure.  These  high-pressure 
methods  engender  laxness  in  self-control.  Men 
permit  themselves  to  become  excited  over  trifles, 
and  fly  into  passions  of  temper  over  trivial  short- 
comings of  subordinates  or  at  fancied  insults. 
They  do  not  put  sufficient  control  upon  their 
nerves,  but  allow  themselves  to  be  continually 
annoyed  and  excited.  They  get  into  a  combative 
state,  and  are  continually  looking  for  trouble. 
They  come  to  live  in  a  tremor,  and  are  irritable 
and  unhappy.  All  this  impairs  their  judgment, 
and  renders  them  capable  of  making  mistakes 
and  incapable  of  doing  good  work.  It  is  a 
tremendous  drain  upon  the  vital  power.  Many 
a  man  helps  to  bring  on  a  breakdown  by 
living    a    life    of    unnecessary  tension   and    using 


384  HOW   TO    KEEP   WELL 

up    his    vital    power    through    failure    to    control 
himself. 

It  is  unwise  for  a  man  to  assume  so  much  busi- 
ness that  he  will  be  obliged  to  labour  up  to  the  full 
extent  of  his  powers.  There  should  be  some 
allowance  made  for  emergencies  when  the  business 
will  suddenly  be  increased.  Anxiety  and  worry 
are  more  exhausting  to  the  physical  powers  than 
actual  labour.  They  cause  rapid  anemia,  and 
loss  of  flesli.  When  worry  is  added  to  responsi- 
bility and  exhausting  labour,  the  breaking-down 
point  is  brought  many  times  nearer.  It  is  a  com- 
mon experience  of  the  physician  to  see  business 
men  go  on  without  apparent  difficulty  until  a 
period  of  panic  and  financial  depression  comes, 
and  then  break  down  at  the  time  it  is  most  impor- 
tant for  them  to  be  on  duty  with  clear  heads.  It 
is  an  insane  captain  who  loads  his  craft  to  the 
water-line  because  he  is  lying  in  a  quiet  harbour. 
It  requires  no  nautical  skill  to  foretell  the  result 
when  a  storm  comes  on.  But  that  is  the  risk  that 
thousands  of  business  and  professional  men  are 
unnecessarily  taking  to-day.  They  are  allowing 
no  margin  for  bad  weather.  The  millennium  is 
not  here,  and  the  age  of  panics  and  business 
depression  is  not  past. 

A  word  may  be  said  regarding  certain  classes  of 


THE  PREVENTION  OF  BREAKDOWN  385 

toilers  who  cannot  change  the  conditions  under 
which  they  are  obhged  to  labour.  They  fill  the 
subordinate  positions  in  the  great  financial  and 
business  institutions.  They  are  fixed  in  a  vise, 
and  must  perform  the  duties  appertaining  to  their 
positions  or  resign.  The  duties  in  many  instances 
cannot  be  divided  or  materially  lightened,  but 
there  are  other  cases  in  which  the  life  of  the 
subordinate  might  be  made  easier.  The  long 
struggle  which  has  preceded  the  rise  to  positions 
of  influence  and  power  has  the  unfortunate  effect 
upon  men  of  some  temperaments  to  harden  and 
render  the  temper  harsh.  They  are  inclined  to 
say  that  they  were  obliged  to  struggle  in  their 
time,  let  the  younger  men  now  take  the  same 
experience.  This  is  certainly  not  universal.  But 
the  experience  of  the  medical  practitioner  leads  him 
to  think  that  there  is  a  strong  growing  tendency 
to  work  to  their  uttermost  the  subordinate  officials 
of  financial  and  mercantile  institutions  who  carry 
heavy  responsibilities,  and  often  handle  large  sums 
of  money,  and,  when  they  fail  to  keep  up  to  the 
standard,  drop  them  and  take  a  younger  man,  to 
put  him  in  his  turn  through  the  same  ordeal. 
The  heads  of  these  institutions  have  often  come  up 
to  their  positions  through  great  struggles.  They 
should  remember,  however,  that  their  success  has 


386  HOW   TO    KEEP   WELL 

been  partly  due  to  native  talent;  that  all  men, 
even  by  the  same  labour,  could  not  attain  the 
same  success. 

Moreover,  while  opportunities  are  greater  to-day 
than  they  have  ever  been  before,  and  the  rewards 
of  success  are  larger,  the  wear  and  tear  in  attaining 
it  has  greatly  increased  in  the  last  thirty  years. 
Though  there  are  more  places,  there  are  more 
applicants,  and  the  struggle  is  more  intense.  Men 
will  do  more  work  in  the  same  time  if  they  are 
not  held  under  too  high  tension.  O  verse  verity 
defeats  its  own  objects.  Prolonged  labour  without 
sufihcient  rest  impairs  the  value  of  the  labourer. 
The  constant  fear  that  any  decrease  of  effective- 
ness will  be  followed  by  loss  of  position  "gets  on 
the  nerves"  and  renders  an  employee  less  efficient. 
The  best  work  cannot  be  done  with  overwrought 
nerves,  and  under  unremitting  high  tension. 

Specialism  is  not  confined  to  the  professions. 
It  is  seen  in  all  branches  of  business  and  among 
day  labourers.  The  f)ld-time  merchant,  whose 
ships  returned  laden  with  all  the  products  of 
Europe  and  the  East,  is  supplanted  by  the  importer 
who  buys  a  single  class  of  goods.  Even  the  depart- 
ment store  is  an  apparent  rather  than  a  real  excep- 
tion to  the  rule.  It  is  an  aggregation  of  different 
branches  of  business,  each  under  the  supervision 


THE  PREVENTION  OF  BREAKDOWN  387 

of  trained  specialists.  Specialism  has  come  to  be 
a  characteristic  of  modern  life.  But  where 
specialism  goes,  there  goes  the  tendency  to  fall 
into  a  rut,  and  a  rut  is  a  very  bad  thing  to  fall  into. 
"When  a  fellow  begins  to  find  out  de  rut  he's  in," 
remarks  that  young  x^hilosopher,  Chimmie  Fadden, 
"it's  up  to  him  for  him  to  climb  out.  If  he  don't 
get  a  move  on  him  then,  the  first  ting  he  knows 
de  rut  is  so  deep  he  can't  climb  out,  nohow  ;  and 
dat  queers  his  nerve."  It  would  be  difficult  to 
compress  more  truth  into  so  little  space.  The  only 
advice  that  could  be  added  is  a  warning  against 
getting  into  a  rut  in  the  first  place.  It  is  easier  to 
keep  out  than  to  get  out. 

The  young  man,  when  he  chooses  his  life  work, 
whether  it  be  a  profession,  business,  or  trade,  puts 
his  whole  mind  and  strength  into  it,  if  he  be  the 
right  kind  of  young  man.  The  more  determined 
he  is  to  succeed,  the  more  intensely  does  he  apply 
himself  to  his  work.  He  associates  with  others 
doing  the  same  work.  Their  ideas  become  his 
ideas;  their  ways,  his  ways.  He  finds  so  much  to 
learn  that  he  is  inclined  to  eliminate  from  his 
reading  and  his  thoughts  all  other  interests. 
"The  lyf  so  short,  the  craft  so  long  to  lerne,"  he 
restricts  himself  more  and  more.  He  loses  interest 
in  other  matters.     Work  becomes  a  second  nature, 


388  HOW   TO    KEEP   WELL 

and  he  is  uncomfortable  when  not  at  work.  As  he 
grows  older  he  restricts  his  work,  perhaps,  to  a 
limited  portion  of  the  business  or  profession  to 
which  he  belongs.  He  is  apt  to  magnify  the 
importance  of  his  own  special  work,  and  minimize 
that  of  others.  His  field  of  vision  becomes  nar- 
rower; he  settles  into  certain  fixed  beliefs,  and 
adopts  certain  methods  of  doing  things.  His  life 
degenerates  into  a  routine,  and  before  he  knows  it 
he  is  in  a  rut.  He  loses  his  interest  in  outside 
matters,  and  is  unhappy  if  he  tries  to  take  a  vaca- 
tion. He  becomes  irritable,  and  is  only  contented 
when  in  the  harness.  As  time  goes  on  he  does  not 
do  his  work  with  vigour  and  energy,  as  of  old,  but 
dawdles  and  becomes  fussy,  and  wastes  time  over 
details.  He  feels  that  there  is  but  one  way  of  doing 
things,  and  that  is  his  way.  Therefore,  he  will  not 
leave  work  to  subordinates  which  the}^  could  do 
as  well  as  he.  When  a  man  detects  these  various 
symptoms  in  himself  he  may  be  sure  that  he  is  in  a 
rut.  There  is  then  one  thing  to  be  done — to  make 
a  vigorous  effort  of  the  will  and  get  out  of  it.  If  he 
cannot  take  a  vacation  without  being  restless  and 
unhappy,  then  a  vacation  is  what  he  needs.  He 
should  force  himself  to  rest.  If  he  has  lost  his 
taste  for  fiction,  then  he  should  read  a  few  good 
stories  each  year,  and  spend  some  time  upon  light 


THE  PREVENTION  OF  BREAKDOWN  389 

literature.  If  he  has  given  up  amusements,  he 
should  begin  going  occasionally  to  a  few  good 
wholesome  places  of  amusement.  He  should  visit 
his  friends  and  renew  the  old  acquaintances  he  has 
dropped.  In  a  little  time,  these  things,  at  first 
irksome,  will  become  pleasures,  and  he  will  be 
taken  away  from  his  cares  and  his  business  \Yorries. 
Gradually  he  will  find  that  he  is  getting  out  of 
the  rut,  and  is  doing  his  work  not  only  easier, 
but  better. 

One  of  the  serious  features  of  life  in  a  rut  is  the 
fact  that  judgment  is  impaired.  Allowing  the 
mind  always  to  dwell  upon  one  subject,  and  keeping 
the  attention  always  fixed  in  one  direction,  destroys 
the  power  to  draw  correct  conclusions,  and  leads  to 
the  adoption  of  distorted  and  peculiar  ideas.  The 
sense  of  proportion  is  lost.  "They  who  always 
labour  can  have  no  true  judgment,"  says  Burke. 
Those  who  get  deeply  fixed  in  a  rut  almost  always 
become  more  or  less  "queer"  as  they  grow  older. 
This  impairment  of  the  judgment  and  one-sided 
way  of  looking  at  things  lead  to  the  adoption  of 
hobbies  and  weird  and  extreme  doctrines.  This 
is  one  of  the  reasons  for  the  prevalence  of  isiiis  and 
queer  theories.  Many  of  those  who  adopt  them, 
even  though  successful  in  business  and  professional 
life,  have  lived  so  long  in  limited  and  restricted 


390  HOW   TO    KEEP   WELL 

channels  that  their  judgment  in  matters  outside 
becomes  impaired.  Their  views  are  narrow  and 
restricted,  and  their  Hves  run  along  a  single  channel. 
If  by  chance  they  make  an  excursion  outside  of  it, 
their  knowledge  of  the  country  is  so  limited  that 
they  are  apt  to  get  lost,  and  either  become  mired  in 
some  bog  of  superstition  or  are  taken  in  by  some 
community  of  fanatics. 

The  wise  man  keeps  out  of  ruts.  To  be  certain, 
however,  that  he  will  accomplish  this,  he  must 
begin  early  in  life.  He  must  not  begin  his  life 
work  by  restricting  himself  absolutely  to  a  certain 
channel.  This  does  not  mean  that  he  should 
scatter  his  forces  and  attempt  everything,  or 
should  not  become  a  specialist.  But  the  more 
strictly  he  specializes,  the  more  certainly  should 
he  see  to  it  that  he  does  not  become  narrow  and 
bigoted.  The  young  man  should  early  begin  the 
habit  of  reading  a  newspaper.  It  should  be  a 
real  newspaper,  and  not  a  yellow  journal  which  will 
cause  his  mental  and  moral  standards  to  degenerate. 
He  will  thus  get  a  general  education  he  can  obtain 
from  no  other  source.  But  he  cannot  get  all  the 
education  he  requires  even  of  public  affair's  from 
the  newspapers.  Let  him  not  make  this  error. 
Their  news  is  necessarily  fragmentary.  He  should 
read  regularly  one  or  two  good  monthly  magazines 


THE  PREVENTION  OF  BREAKDOWN  391 

of  the  class  devoted  to  the  discussion  of  questions 
of  public  interest.  He  should  read  a  little  good 
fiction,  as  well  as  history  and  general  literature. 
While  he  should  persistently  seek  the  acquaintance 
of  the  best  men  of  his  own  craft,  who  are  usually 
the  broadest  minded,  he  should  also  seek  friends 
outside  of  it.  They  will  help  him  to  see  that  there 
are  other  important  crafts  in  the  world  besides  his 
own.  All  this  will  broaden  his  views  and  help  to 
keep  him  out  of  a  rut. 

If  he  finds  he  is  becoming  a  specialist  (the  term 
is  used  in  its  broad  sense  to  include  any  man  who 
restricts  his  business  to  narrow  limits),  he  should 
adopt  further  measures,  even  to  the  taking  up  of 
a  fad.  "Fads  constitute  a  mental  antitoxin  to 
the  poison  generated  by  cerebral  overactivity," 
sa3^s  Pyle.  This  has  been  a  measure  adopted  by 
many  intense  workers.  William  H.  Vanderbilt 
believed  that  his  life  was  prolonged  by  the  daily 
driving  of  his  horses,  which  he  took  up  as  a  means 
of  diverting  his  mind  from  the  cares  of  business, 
rather  than  for  pure  pleasure.  His  eldest  son  died 
a  comparatively  young  man,  largely  as  the  result, 
it  was  believed,  of  too  close  application  to  business. 
Chauncey  M.  Depew  has  repeatedly  said  that 
public  speaking  is  for  him  a  method  of  recrea- 
tion.    Literature  has  been  adopted  by  Roosevelt, 


392  HOW    TO    KEEP   WELL 

Gladstone,  Disraeli,  and  many  others.  Lord 
Salisbury  is  a  scientist  of  large  attainments,  and 
has  always  done  much  work  in  his  laboratory, 
which  is  one  of  the  best  in  England.  He  adopted 
this  means  of  escape  from  the  crushing  cares 
which  rest  upon  the  virtual  head  of  a  great  empire. 
The  present  Prime  Minister  takes  refuge  in  litera- 
ture and  golf.  Some  men  adopt  hunting,  fishing, 
golf,  and  similar  sports.  Others  choose  photog- 
raphy, microscopy,  or  become  collectors  of  this 
or  that,  or  make  themselves  experts  upon  some 
branch  of  art.  Others,  with  a  musical  talent, 
become  proficient  in  some  branch  of  that  art. 
The  point  is  simply  this,  that  it  is  wise  for  a  person 
to  take  up  some  subject  for  which  he  has  special 
liking  or  aptitude  with  which  he  may  divert  his 
mind  from  tlie  anxieties  and  worries  of  his  daily 
work.  It  is  not  a  theoretical  proposition,  but  an 
eminently  practical  one,  which  has  been  utilized 
for  years,  and  is  utilized  to-day  more  than  ever 
before.  Elaborate  fads  like  literature,  music, 
and  art  are  not  necessary.  A  prominent  and  very 
successful  New  York  lawyer  has  a  fad  for  baseball. 
He  is  a  frer|uent  attendant  at  the  league  games, 
where  he  enters  into  the  spirit  of  the  sport,  and 
obtains  complete  relaxation  from  professional 
care3.     During    other    portions    of    the    year    he 


THE  PREVENTION  OF  BREAKDOWN  393 

escapes  from  them  in  public  speaking,  which  native 
talent  and  experience  enable  him  to  look  upon 
as  a  relaxation.  Some  simple  and  inexpensive 
means  of  diversion  are  within  the  reach  of  every 
one. 

A  well-known  New  York  physician  used  to  say 
that  he  could  do  a  year's  work  in  eleven  months, 
but  could  not  do  it  in  twelve.  The  annual  vaca- 
tion is  one  of  the  most  efficient  defensive  weapons 
against  breakdown  for  those  who  live  the  intense 
modern  life.  If  it  be  a  sedentary  one,  tlie  neces- 
sity of  the  vacation  is  the  greater.  It  is  greater 
still  if  it  be  like  that  of  the  busy  doctor,  which 
knows  neither  evenings  nor  nights,  Sundays  nor 
holidays,  but  is  an  unremitting  grind,  month  after 
month.  The  vacation  is  one  of  the  most  potent 
aids  in  helping  to  keep  out  of  the  rut  into  which 
the  daily  routine  of  life  tends  to  force  one.  One 
or  two  days  a  week  during  the  summer  do  not 
afford  sufficient  rest  for  the  hard-working  business 
man.  They  are  very  beneficial,  but  do  not  per- 
mit him  to  really  step  from  beneath  his  burdens 
and  feel  that  he  is  free  from  care.  I  appreciate 
fully  that  it  is  very  difficult  for  many  men,  and 
absolutely  impossible  for  others,  to  escape  from 
their  responsibilities  for  m.ore  than  a  day  or  two  at 
a  time.      It   could   often  be   done,   however,   if  its 


394  HOW   TO    KEEP    WELL 

importance  were  appreciated.  Many  a  man  has 
learned  a  lesson  from  an  illness.  After  years  of 
closest  application  to  business  he  has  been  forced 
by  disease  to  remain  away  from  business,  and  has 
been  surprised  and  a  little  annoyed  to  find  that 
affairs  moved  on  pretty  well  without  him.  It  is 
the-  duty  of  every  man  to  attempt  to  arrange  his 
affairs  so  that  he  may  leave  them  to  others  if  it  is 
necessary.  Accident  or  illness  may  come  to  any 
man  without  warning,  and  they  are  rendered  far 
more  serious  by  worry  over  business.  If  he  pre- 
pares for  such  emergencies  the  best  he  may  be  able, 
he  will  hnd  it  easier  to  arrange  for  a  vacation.  If 
he  decides  upon  it  in  a  half-hearted  way,  to  be 
taken  if  convenient,  he  will  probably  not  find  it 
possible.  If  the  time  is  set  for  it  with  the  full 
expectation  of  going  away  when  the  time  comes, 
affairs  are  much  more  likely  to  arrange  them- 
selves favourably.  The  way  to  take  a  vacation 
is  to  set  the  time  and  take  it  when  the  time  comes. 
There  is  some  locality,  north  or  south,  favourable 
for  a  vacation  at  every  season  of  the  year.  If  it 
cannot  be  taken  in  the  summer,  it  may,  perhaps, 
be  arranged  for  at  some  other  season. 

After  fifty,  the  importance  of  the  annual  vaca- 
tion becomes  greater  each  year.  A  man  should 
rid  himself  of  the  idea  that  a  vacation  is  a  simple 


THE  PREVENTION  OF  BREAKDOWN  395 

matter  of  pleasure  or  a  mild  form  of  dissipation. 
He  should  regard  it  as  a  duty  to  himself  and  to 
his  family,  and  should  plan  for  it  as  a  necessary 
hygienic  measure.  Even  though  he  goes  into  the 
country  each  night,  he  should,  if  it  is  possible, 
stay  entirely  from  his  business  for  two  weeks  at 
least,  and  longer  if  he  can.  As  there  are  many  men 
of  many  minds,  so  there  are  as  many  ways  of 
spending  a  vacation  as  there  are  individuals.  The 
one  rule  should  be  to  live  a  life  different  from  that 
of  the  rest  of  the  year,  taking  the  precaution  not 
to  overdo  the  strength.  The  man  of  sedentary 
habits,  unaccustomed  to  vigorous  and  protracted 
exercise,  may  destroy  much  of  the  good  of  his 
vacation  by  entering  at  once  upon  mountain 
climbing,  extended  tramps,  prolonged  bathing,  or 
excessive  exercise.  Some  people  seem  to  be  pos- 
sessed of  the  demon  of  unrest  when  they  get  into 
the  country,  and  act  as  though  they  expect  to 
atone  for  the  sins  of  their  months  of  sluggishness 
by  a  few  weeks  of  overexercise.  As  a  rule,  exercise 
during  vacation  is  overdone  rather  than  underdone. 
The  summer  hotel,  the  cottage,  or  the  camp 
may  not  be  as  comfortable  as  the  home.  But  if 
people  stay  at  home  they  will  stay  also  in  the  rut. 
The  most  valuable  result  of  a  vacation  is  to  get 
busy  men  and  women  out  of  their  ruts,  to  take 


396  HOW   TO    KEEP   WELL 

them  away  from  themselves  and  their  everyday 
cares,  and  remove  them  from  their  usual  routine  of 
life.  If  it  is  rationally  spent,  it  is  worth  all  that 
it  costs  in  money  and  trouble. 

There  is  one  important  class  of  city  workers 
whose  members  need  vacations  but  seldom  get 
them.  They  are  the  wives  of  well-to-do  business 
and  professional  men,  and  women  of  the 
wealthier  classes,  who  do  not  belong  to  the  ultra 
society  set.  They  live  in  private  houses  or  expen- 
sive apartments,  and  have  most  of  the  things  they 
wish  for  in  life  except  rest.  The  routine  of  their 
lives  consists  in  supervising  their  households, 
managing  the  servants,  planning  the  meals, 
caring  for  the  children,  keeping  their  wardrobes 
up  to  date,  and  performing  more  or  less  exacting 
social  duties.  In  the  summer  the  household  is 
transferred  bodily  to  a  "cottage"  or  "camp." 
It  must  be  supervised  as  in  the  city;  the  servants 
must  be  managed;  the  endless  routine  of  meals 
can  never  be  forgotten;  the  children  cannot  be 
neglected;  the  social  duties,  though  different,  are 
always  present,  for  a  series  of  guests  must  be 
entertained.  And  so  this  woman,  fortunate  in 
most  things,  is  a  prisoner  to  routine  summer  and 
winter  alike.  One  of  these  women  recently  told 
me  that  in  nine  years  of  married  life  she  had  had 


THE  PREVENTION  OF  BREAKDOWN  397 

but  a  month's  freedom  from  this  routine.  And 
yet  people  wonder  that  these  women  have  nervous 
prostration  or  some  other  form  of  breakdown. 
Husbands  are  sometimes  very  obtuse,  and  seek 
every  cause  but  the  right  one.  This  summer 
cottage  life  is  vastly  better  for  the  father  and  the 
children  than  hotel  life  is,  but  it  has  its  disadvan- 
tages for  the  wife  and  mother.  She  is  the  only 
one  of  the  family  who  gets  no  vacation.  This  is 
obviated  in  many  cases  by  taking  the  meals  in 
a  nearby  hotel  or  club-house.  When  such  an 
arrangement  is  not  possible,  an  effort  should  be 
made  to  give  the  wife  a  respite  from  these  ever- 
monopolizing  household  cares  for  at  least  a  short 
time  each  year.  The  high  tension  of  modern  life 
does  not  affect  the  men  alone.  Their  wives  feel 
it  as  well.  With  the  rapidly  increasing  scale  of 
living,  the  management  of  a  household  is  now  far 
more  difficult  than  it  was  one  or  two  generations 
ago.  The  average  woman  at  the  head  of  a  city 
establishment  to-day  keeps  more  servants,  dis- 
burses more  money,  and  has  more  responsibilities 
than  her  mother  had,  and  vastly  more  than  her 
grandmother.  The  wear  and  tear  upon  her 
physical  and  nervous  systems  is  correspondingly 
greater.  The  modern  woman  needs  an  opportunity 
to  get  out  of  the  rut  as  much  as  her  husband  does. 


398  HOW   TO    KEEP   WELL 

"If  men  would  but  observe  the  golden  Mean  in 
all  their  Passions,  Appetites,  and  Desires;  and  if  in 
their  Gratifications  they  followed  the  uncorrupt 
Dictates  of  Nature,  and  neither  spurred  her  on 
beyond  her  Cravings,  nor  violently  restrained 
her  in  her  innocent  Bias,  they  would  enjoy  a  greater 
Measure  of  Health  than  they  do,  live  with  less  Pain, 
and  die  with  less  Horror."  These  words  of  George 
Cheyne  are  full  of  wisdom,  and  their  observance 
would  correct  much  erroneous  living.  One  of  the 
most  common  causes  of  breakdown  is  faulty  diet. 
One  point,  alone,  may  be  referred  to  here,  namely, 
the  luncheon  of  many  business  men.  Go  into  a 
downtown  restaurant  in  New  York  near  noon, 
be  it  cheap,  middle-class,  or  high-grade,  and  take 
note  of  the  stuff  that  composes  the  lunch  of  many 
of  the  men,  presumably  sane.  It  often  tends 
to  shake  one's  respect  for  human  nature.  It 
demonstrates  what  some  men  are  capable  of  when 
out  of  the  protecting  care  of  their  wives.  Some  of 
these  men  we  know  will  seek  sympathy  at  home 
because  of  the  cares  of  business  life  when  the  real 
trouble  with  them  is  downtown-lunch  dyspepsia. 

Irregular  hours  and  too  little  sleep  are  other 
factors  in  causing  early  breakdown.  Sleep  is  an 
absolute  requisite  of  nature.  Different  tempera- 
ments require  different  amounts  of  sleep,  but  there 


THE  PREVENTION  OF  BREAKDOWN  399 

are  very  few  who  can  keep  healthy  and  well  on 
less  than  eight  hours.  Continuous  curtailing  of 
the  sleep,  even  if  it  be  slight,  is  more  serious  than 
the  occasional  loss  of  many  hours.  It  renders  the 
mind  heavy  and  sluggish,  and  few  other  things  will 
so  diminish  the  power  to  do  good  work.  In  time 
even  a  small  daily  loss  will  tell  upon  the  health. 
If  to  this  is  added  frequent  heavy  losses  of  sleep, 
with  eating  and  drinking  late  at  night,  by  a  man 
who  carries  heavy  business  or  professional  burdens, 
we  have  all  the  conditions  for  disaster  soon  after 
middle  life.  The  irregular  life  of  the  society  man 
or  man-about-town  cannot  be  combined  with 
that  of  the  strenuous  business  man  with  impunity. 
The  subject  of  tobacco  is  necessarily  included 
in  this  chapter.  Like  all  elements  which  have  an 
effect  upon  the  nerves,  it  differs  widely  in  its  action 
upon  different  individuals,  and  no  sweeping  state- 
ments can  be  made.  Upon  most  constitutions 
its  action  is  deleterious.  It  is  always  injurious 
before  the  period  of  complete  development,  and 
cannot  be  used  before  the  age  of  twenty-five 
without  harm.  Doctor  Seaver,  Director  of  the 
Physical  Laboratory  at  Yale,  tabulated  the  record 
of  the  students  entering  that  university  during 
nine  years,  when  all  the  young  men  were  examined 
and    measured.     The    smokers    averaged    fifteen 


400  HOW   TO    KEEP   WELL 

months  older  than  the  non-smokers.  They  were 
also  shorter  in  stature.  Nicotine  interferes  with 
growth,  and  its  effect  in  that  regard  is  very  measur- 
able. At  Yale,  during  the  four  years'  course, 
the  non-users  of  tobacco,  although  taller  when  they 
enter,  gain  24  per  cent,  more  in  height  and  26.7 
per  cent,  more  in  girth  of  chest  than  do  the  habitual 
users.  Doctor  Hitchcock,  of  Amherst  College, 
found  even  greater  differences.  The  difference  in 
the  lung  capacity  is  very  striking  in  the  two  classes, 
and  has  been  noticed  by  all  observers.  It  shows 
the  effect  of  tobacco  on  the  respiration,  nicotine 
being  a  potent  motor-depressant.  As  regards  the 
effect  of  nicotine  on  the  mental  processes,  it  is 
more  difficult  to  interpret  the  meaning  of  statistics. 
Out  of  the  highest  scholarship  men  at  Yale,  only 
5  percent,  use  tobacco,  while  of  the  men  who  do 
not  get  appointments,  90  per  cent,  use  it.  It  is 
not  necessary  to  interpret  this  as  meaning  that 
mental  decrepitude  follows  the  use  of  tobacco 
by  young  men,  for  there  are  other  factors  to  be 
considered,  but  it  is  certainly  not  conducive  to 
the  best  work. 

Nicotine  is  the  most  active  element  in  tobacco. 
Its  immediate  effect  is  to  lower  the  circulation, 
quicken  the  respiration,  and  excite  the  muscular 
system;  its  final  effect,  to  cause  general  relaxation. 


THE  PREVENTION  OF  BREAKDOWN   401 

In  "tobacco  heart"  the  heart's  action  becomes 
irregular  and  irritable,  and  the  walls  are  hyper- 
trophied  or  thickened.  There  is  no  cure  without 
stopping  the  tobacco.  The  tendency  to  increase 
the  amount  of  tobacco  is  almost  irresistible.  It 
is  a  safe  and  wise  rule  for  the  user  to  occasionally 
take  honest  account  of  the  amount  used  and  reduce 
it  half.  If  tobacco  could  be  banished  entirely, 
there  would  be  fewer  irritable  and  nervous  men 
in  the  community.  We  may  once  more  quote  our 
old,  old  friend,  George  Cheyne:  "Smoking  tobacco 
may  be  useful  to  flegmatic  Constitutions,  but  to 
dry  and  lean  Habits  it  is  pernicious.  Snuff  is  just 
good  for  nothing  at  all." 

With  the  possible  exception  of  bad  diet  and 
methods  of  eating,  alcoholic  drinking  is  the  most 
fruitful  cause  of  human  breakdown.  The  phys- 
ical questions  are  so  interwoven  with  the  moral 
that  it  is  a  very  difficult  subject  to  write  upon 
from  the  standpoint  of  physical  effects  alone. 
The  dangers  of  excess  and  habit,  and  the  sad 
results  when  it  becomes  the  master,  are  universally 
recognized.  Its  power  to  cause  suffering  and  ruin 
need  not  here  be  entered  upon.  One  point  only 
will  be  considered — the  physical  effects  of  so- 
called  moderate  drinking.  This  commonly  used 
term  is  indefinite,  for  what  is  moderation  for  one 


402  HOW   TO    KEEP   WELL 

may  be  excess  for  another.  We  may  say,  in  its 
stead,  the  daily  or  frequent  use  of  considerable 
amounts  of  alcoholic  drink,  but  not  sufficient  to 
cause  symptoms,  and  perhaps  never  intoxication. 
In  speaking  of  those  men  who  thtis  drink  and 
think  it  does  them  no  harm,  Doctor  Osier,  whose 
opinion  is  respected  by  medical  men  on  two 
continents,  speaks  as  follows:  "During  the  fifth 
decade,  just  as  business  and  political  success  is 
assured,  Bacchus  hands  in  heavy  bills  for  pay- 
ment in  the  form  of  serious  diseases  of  the  arteries 
or  of  the  liver  and  kidneys,  or  there  is  a  general 
breakdown."  This  is  a  statement  of  a  physio- 
logical truth  in  very  plain  and  unmistakable 
language.  While  a  few  constitutions  seem  to 
tolerate  much  more  than  the  average,  the  fact 
remains  that  alcohol  is  an  insidious,  treacherous, 
and  dangerous  element.  Its  use  in  con- 
siderable daily  quantities  is  always  productive 
of  harm. 

Again  it  may  be  said  that  breakdown  is  by  no 
means  a  necessary  result  of  our  intense  modern 
life.  There  is  more  to  provoke  it  than  there  has 
ever  been  before,  but  at  the  same  time  we  have 
more  means  at  our  hand  to  prevent  it  if  we  will 
utilize  them. 


CHAPTER  XVI 
Diseases  Common  to  Middle  Life 

There  are  several  diseases  whose  occurrence 
is  particularly  common  between  forty  and  sixty 
years.  Few  of  them,  however,  are  strictly  limited 
to  that  period  of  life,  and  none  are  inevitable  to 
it.  Much  may  be  done  by  care  and  right  methods 
of  living  to  prevent  most  of  them.  The  most 
important  of  these  diseases  are  Bright 's  disease, 
degeneration  of  the  arteries,  gout,  the  uric  acid 
condition,  diseases  of  the  liver,  fatty  degenera- 
tions, heart  disease,  diabetes,  obesity,  and  cancer. 

These  diseases  may  be  characterized  as  personal 
diseases.  By  this  I  mean  that  they  are  the  result 
of  inherited  or  inherent  tendency,  or  the  outcome 
of  personal  habits  or  modes  of  life.  They  are  the 
natural  outgrowth  of  temperament,  habit,  and 
environment.  They  differ  materially  in  this  regard 
from  the  infectious  diseases,  which  do  not  depend 
essentially  upon  temperament  or  inherited  tend- 
ency, but  come  as  accidents  come.  The  child  of  a 
gouty  family  is  no  more  or  no  less  liable  to  con- 

403 


404  HOW   TO   KEEP   WELL 

tract  measles  upon  exposure  than  is  one  of  a 
rheumatic  or  tubercular  family.  Individuals  of 
all  temperaments  become  ill  with  typhoid  fever 
if  they  take  typhoid  germs  with  their  food.  More- 
over, the  infectious  diseases  run  a  very  similar 
course  in  different  patients,  passing  through  the 
same  stages  and  being  subject  to  the  same  compli- 
cations. They  are,  in  fact,  accidents,  and  may 
suddenly  befall  those  who  are  in  perfect  health. 
They  are,  therefore,  among  the  most  preventable 
of  diseases.  Railroad  accidents  sometimes  occur 
in  spite  of  modern  inventions  to  prevent  them,  but 
they  are  no  longer  looked  upon  as  inevitable,  or 
as  acts  of  Providence.  The  best-managed  roads 
have  fewest  accidents,  and  in  the  same  way  many 
of  the  infectious  diseases  are  preventable,  but 
owing  to  the  tendency  of  finite  man  to  be  careless, 
and  to  neglect  necessary  precautions,  they  con- 
tinue to  occur.  Most  of  the  personal  diseases 
considered  in  this  chapter  are  preventable  also, 
but  in  a  very  different  way.  Prevention  of  the 
infectious  diseases  consists  largely  in  avoiding 
the  germs  that  cause  them.  Prevention  of  these 
personal  diseases  involves  perpetual  caution 
and  the  adoption  of  particular  modes  of  living. 
The  one  involves  the  occasional  dodging  of  missiles, 
the  other  walking  along  a  straight  and  sometimes 


DISEASES  COMMON  TO  MIDDLE  LIFE  405 

very  narrow  way.  The  one  requires  knowledge 
and  caution  at  intervals,  the  other  self-control 
and  temperance  in  all  things. 

In  another  regard,  these  two  classes  of  disease 
may  be  called  personal  and  impersonal.  Most  of 
the  infectious  diseases  may  Vje  prevented  in  large 
measure  by  the  public  authorities,  so  that  the 
most  ignorant  and  careless  are  protected  from 
them.  Yellow  fever  was  thus  stamped  out  in 
Havana.  But  no  board  of  health  can  reduce 
by  a  single  case  the  occurrence  of  Bright 's  disease, 
diabetes,  or  gout.  Prevention  rests  wholly  with 
the  individual;  it  is  wholly  personal.  The  methods 
required  are  prolonged  and  continuous,  and  are 
summed  up  in  the  expression  so  often  used  in  these 
pages,  right  living.  It  goes  without  saying  that 
each  disease  requires  special  measures.  But  the 
disease  being  personal  and  individual,  each  case 
requires  personal  and  individual  management. 
It  is  a  fundamental  principle  among  doctors  that 
in  most  cases  the  patient  must  be  treated,  rather 
than  the  disease.  This  is  true  even  of  the  con- 
tagious diseases,  but  it  is  many  times  more  true  of 
the  personal  diseases.  "If  a  doctor  has  science 
without  common  sense,"  says  Oliver  Wendell 
Holmes,  "he  treats  a  fever,  but  not  his  man's 
fever.     If  he  has  common  sense  without  science, 


4o6  HOW   TO    KEEP   WELL 

he  treats  his  man's  fever  without  knowing  the  laws 
that  govern  all  fevers  and  vital  processes." 

It  is  impossible  to  honestly  lay  down  hard  and 
fast  rules  which  will  be  adequate  for  every  case, 
either  for  prevention  or  treatment.  No  one  but 
the  quack  attempts  it.  Be  assured  that  the  man 
who  claims  to  have  a  "sure  cure"  for  one  of  these 
personal  diseases,  without  reference  to  the  form-  of 
disease  or  the  individual  who  has  it,  is  a  quack,  and 
unworthy  of  confidence.  And  yet  it  is  for  these 
personal  disorders,  which  are  so  largely  modified 
by  heredity,  temperament,  and  mode  of  life,  that 
the  greatest  number  of  sure  cures  are  advertised. 
What  would  be  thought  of  a  doctor  who  would 
prescribe  for  B right's  disease  without  an  examina- 
tion, or  the  asking  of  a  single  question,  upon  the 
diagnosis  of  a  patient  so  ignorant  of  disease  that 
he  does  not  know  that  there  are  half  a  dozen 
distinct  diseases  going  under  the  one  common 
name?  But  this  is  precisely  what  the  patent 
medicine  man  does  in  every  case.  He  offers  one 
method  of  treatment  for  half  a  dozen  or  more 
personal  diseases,  which  assume  as  many  forms  as 
there  are  patients  suffering  from  them.  There  are 
methods  of  treatment  proposed  which  guarantee 
perfect  health  through  the  following  of  a  few  rules, 
each  more  absurd  than  the  other.     Such  systems 


DISEASES  COMMON  TO  MIDDLE  LIFE  407 

of  treatment,  being  simple  and  easy  to  follow,  are 
captivating,  and  have  their  vogue  until  their 
inadequacy  is  discovered.  Any  system  which 
lays  down  a  few  arbitrary  rules  which  are  posi- 
tively asserted  to  apply  to  every  case  will  secure 
£.  certain  popular  favour.  The  man  who  has  no 
hobby  to  exhibit  to  the  public,  and  no  financial  ax 
to  grind,  finds  the  subject  of  dietetics  and  the 
prevention  of  the  personal  diseases  a  difficult  one 
to  handle.  The  people  persistently  cry  "Show  us 
a  miracle,"  but  there  is  no  miracle  which  the  honest 
man  can  show.  There  is  no  simple  list  of  rules  the 
following  of  which  will  insure  to  every  one  perfect 
health.  There  is  no  short  cut,  or  path  that  is 
perfectly  easy.  The  royal  road  to  health  is  the 
rather  irksome  one  of  self-control,  moderation, 
and  temperance  in  all  things.  In  these  pages  I 
have  attempted  to  be  as  explicit  and  definite  as 
the  subject  will  permit,  but  in  personal  diseases 
the  personal  element  can  never  be  ignored.  It 
will  persist  in  thrusting  itself  forward,  both  in 
theory  and  in  practice,  to  render  sweeping  state- 
ments and  positive  assertions  impossible  if  truth- 
fulness is  preserved. 

It  is  in  the  treatment  of  such  conditions  that  the 
skill  of  the  experienced  physician  is  most  manifest. 
If  every  one  inherited  the  same  tendencies,  pos- 


4o8  HOW    TO    KEEP    WELL 

sessed  the  same  bodies,  and  had  suffered  from  the 
same  diseases,  the  practice  of  medicine  would  be 
comparatively  easy.  Many  people  forget  these 
factors,  and  suppose  that  each  disease  is  an  entity 
which  appears  the  same  in  every  patient.  They 
seem  to  think  that  a  doctor  has  certain  pre- 
scriptions for  certain  diseases,  and,  the  diagnosis 
having  been  made,  he  merely  uses  the  appropriate 
prescription.  I  once  received  a  letter  containing 
not  a  word  of  explanation,  but  asking  me  to  send 
as  soon  as  possible  my  "best  prescription  for 
Bright 's  disease."  A  patent  medicine  man  could 
have  answered,  of  course,  without  hesitation.  A. 
judge  would  be  unwilling,  even  if  he  had  the  power, 
to  pass  sentence  upon  a  person  who  was  said  by 
some  one  to  have  committed  a  certain  crime.  He 
would  hear  and  sift  the  evidence,  and  make  the 
penalty  fit  the  crime  if  one  had  been  committed. 
And  so  a  careful  and  competent  physician  holds 
court  upon  every  case,  sifts  a  mass  of  confused 
and  often  conflicting  evidence,  and  prescribes  the 
treatment  which  his  judgment  leads  him  to  think 
is  indit^ated.  Thus,  to  two  patients  having  a  dis- 
ease bearing  the  same  name,  he  may  give  entirely 
different  prescriptions,  and  advise  a  radically 
different  diet.  A  tailor  who  would  advertise  that 
he  made  all  coats  of  one  piece  of  goods,  and  of  one 


DISEASES  COMMON  TO  MIDDLE  LIFE  409 

size,  would  not  do  a  lucrative  business.  But  his 
neighbour,  the  patent  medicine  man,  who  adver- 
tises one  medicine  for  every  case,  will  become  rich 
if  he  advertises  enough  and  keeps  a  sufficient 
number  of  clerks  employed  in  writing  testimonials. 
The  boy  and  the  geese  who  now  adorn  so  many 
public  places  are  a  most  apt  satire  upon  the  people 
who  buy  cure-alls.  If  a  clever  and  competent 
physician  were  to  advertise  his  own  skill  as  the 
quack  does,  he  would  not  claim  to  treat  every 
patient  with  one  prescription,  but  would  rather 
advertise  treatment  to  fit. 

bright's  disease 
Under  this  comprehensive  term  is  included 
several  diseases  of  the  kidneys,  whose  technical 
name  is  nephritis.  They  were  first  clearly  defined 
in  1827  by  Doctor  Richard  Bright,  of  England, 
after  whom  they  were  named.  Bright's  disease 
may  be  either  acute  or  chronic.  There  is  a  popu- 
lar impression  that  the  disease  is  virtuall}^  incurable, 
and  a  cure  is  regarded  as  little  less  than  a  miracle. 
As  a  matter  of  fact,  acute  nephritis  tends  to  recovery, 
but  the  chances  of  recovery  are  better  in  young 
adults  than  in  those  past  middle  life.  It  is  com- 
mon to  all  ages.  It  is  caused  by  exposure  to  wet 
and  cold,  particularly  in  those  under  the  influence 
of  alcohol.     It  occurs  also  in  the  course  of  some 


4IO  HOW   TO    KEEP   WELL 

of  the  infectious  diseases,  especially  scailet  fever. 
It  may  be  caused  by  overdoses  of  such  drugs  as 
turpentine,  carbolic  acid,  and  chlorate  of  potash. 
It  is  this  form  of  kidney  disease  that  sometimes 
occurs  during  pregnancy.  It  is  evident  that  a 
person  who  is  ordinarily  careful  in  avoiding  exposure 
can  do  but  little  more  to  prevent  acute  Bright's 
disease.  It  may  come  to  him  as  does  bronchitis 
or  the  ordinary  catarrhal  diseases. 

Chronic  Bright's  disease  occurs  under  two  dis- 
tinct forms,  the  first  being  known  as  diffuse 
nephritis  and  the  second  as  cirrhosis  of  the  kidney. 
The  first  is  more  common  among  young  adults 
than  it  is  in  middle  life.  It  is  sometimes  the  result 
of  an  acute  attack,  the  disease  slowly  passing  into 
a  chronic  condition,  but  it  frequently  begins 
insidiously.  The  use  of  alcohol,  particularly  beer, 
is  believed  to  lead  to  this  form  of  nephritis.  It 
sometimes  complicates  consumption  and  chronic 
heart  disease.  When  it  has  continued  for  a  year 
the  probability  of  recovery  is  extremely  small. 

The  most  characteristic  form  of  Bright's  disease, 
common  to  middle  life,  is  cirrhosis  of  the  kidney, 
sometimes  known  as  contracted  kidney  and  gouty 
kidney.  It  is  chronic  from  the  outset,  and  is  a 
slow,  insidious  degeneration  of  the  kidney  tissue. 
The  causes  in  some  cases  are  clearly  apparent;  in 


DISEASES  COMMON  TO  MIDDLE  LIFE  411 

others  they  are  doubtful,  and  can  never  be  deter- 
mined with  certainty.  Alcohol  plays  an  important 
part  in  many  cases,  but  among  the  well-to-do 
classes  overeating  is  a  more  prominent  factor  than 
overdrinking.  The  excessive  eating  of  meat  by 
sedentary  workers,  and  the  drinking  of  much  beer, 
throws  labour  upon  the  kidneys  which  may  prove 
very  injurious.  The  strain  and  anxiety  of  busi- 
ness, combined  with  overeating  and  lack  of  exer- 
cise, may  result  in  chronic  kidney  disease.  It  is 
much  more  common  in  men  than  in  women,  and  is 
particularly  common  among  active  business  and 
professional  men.  In  England,  gout  is  frequently 
a  cause,  and  in  this  country  its  near  relative,  the 
uric  acid  condition,  is  a  factor  in  its  production. 
It  is  not  an  infrequent  disease  among  active  brain 
workers. 

Chronic  Bright 's  disease  is  determined  with  most 
certainty  by  an  examination  of  the  urine.  The 
signs  which  indicate  its  presence  are  albumin  and 
"casts."  The  absence  of  albumin  at  a  single 
examination  is  not  always  conclusive  in  this  type 
of  disease,  for  its  amount  is  rarely  large  and  it  some- 
times disappears  for  short  intervals.  Casts  are 
little  oblong  bodies  which  come  from  the  tubules 
of  the  kidneys,  and  are  discovered  b}^  the  micro- 
scope.    The  two  found  together  indicate  nephritis. 


412  HOW   TO    KEEP   WELL 

Notwithstanding  this  fact,  Doctor  Osier  wrote  an 
article  not  long  since  upon  the  advantages  of  a 
trace  of  albumin  and  a  few  tube  casts  in  certain 
men  more  than  fifty  years  of  age.  The  explanation 
of  this  strange  proposition  was  something  as  follows : 
The  successful  business  or  professional  man,  who 
lives  intensely  and  strives  hard  to  get  wealth  or 
reputation,  and  who  takes  plenty  of  food  three 
times  a  day,  with  two  or  three  glasses  of  spirits, 
and  smokes  six  or  ten  cigars,  is  not  leading  a 
rational  life.  The  body  bears  many  resemblances 
to  a  steam  engine.  In  the  one  as  in  the  other,  fuel, 
combustion,  transformation  of  energy,  and  the 
accumulation  of  waste  materials  tell  the  story  of 
the  day's  work.  The  engineer  understands  his 
machine,  and  accommodates  the  amount  of  coal 
burned  to  the  size  of  the  engine  and  to  the  amount 
of  work  required.  The  waste  pipes,  which  in  the 
human  machine  are  the  kidneys,  bear  the  strain 
of  the  extra  work  when  the  amount  of  fuel  con- 
sumed and  energy  liberated  is  out  of  all  proportion 
to  the  work  demanded.  Careless  stoking  with  high 
pressure  for  twenty-five  years,  and  bad  treatment 
of  the  human  machine,  mean  early  degenerations, 
and  the  waste  pipes  are  often  the  first  to  show 
signs  of  ill  usage.  It  is  a  great  shock  to  a  man 
when  he  is  some  dav  informed   bv  an  insurance 


DISEASES  COMMON  TO  MIDDLE  LIFE  413 

company  that  he  has  been  "postponed,"  and  had 
better  consult  his  family  physician.  After  a  period 
of  great  distress  and  worry,  he  begins  to  take 
heart,  and  on  the  advice  of  his  physician  remodels 
his  mode  of  life.  He  restricts  his  appetite,  takes  a 
light  lunch  and  a  moderate  dinner,  gives  up 
whisky  and  champagne,  resigns  from  six  or  eight 
boards,  and  at  fifty  starts  to  live  a  rational  life. 
"Prospectively,"  says  Doctor  Osier,  "nothing 
could  have  been  more  advantageous  than  the 
discovery  in  the  urine  of  a  trace  of  albumin  and 
a  few  tube  casts." 

Signs  of  kidney  involvement  are  not  uncommon 
during  and  after  middle  life.  With  proper  pre- 
cautions and  the  living  of  a  rational  life  many  men 
who  have  shown  them  live  for  years  in  the  posses- 
sion of  excellent  health.  In  fact,  such  trouble 
may  not  shorten  life. 

On  the  other  hand,  there  are  some  cases  in 
which  the  discovery  of  albumin  and  casts  is 
more  serious.  Their  significance  depends  upon 
the  form  of  disease  present  and  its  cause,  which 
must  be  determined  by  the  attending  physician. 
They  may  mean  serious  trouble  ahead,  or  may 
only  be  red  lights  which  give  warning  of  danger 
and  indicate  the  necessity  of  slowing  up  and 
running     a     less     rapid     pace.       But     under     no 


414  HOW   TO    KEEP   WELL 

circumstances    can    they    be     disregarded    with 
safety. 

But  little  need  be  said  further  upon  the  preven- 
tion of  Bright 's  disease.  The  causes  have  been 
explained,  and  the  intelligent  man  will  not  find  it 
difficult  to  deduce  modes  of  prevention.  It  is 
easy  to  say  that  there  should  be  less  work  and  rush 
and  intensity  of  living  when  middle  life  is  reached, 
and  very  hard  to  follow  such  advice.  They 
probably  never  alone  cause  Bright 's  disease,  but 
may  hasten  it  in  certain  temperaments  in  con- 
junction with  other  things.  But  if  to  this  intense 
business  life  are  added  exhausting  recreations,  late 
hours,  excessive  use  of  malt  and  spirituous  liquors, 
and  above  all  a  heavy  and  excessive  diet,  rich  in 
nitrogenous  matter,  a  man  need  not  be  surprised 
when  he  is  nearing  fifty  if  his  doctor  tells  him  some 
day  that  he  has  a  little  trouble  with  his  kidneys. 
It  may  not  be  too  late  to  save  himself  by  a  rational 
change  in  his  mode  of  living.  Not  every  train  that 
runs  into  an  open  switch  is  destroyed,  but  there  is 
always  danger,  and  it  is  safer  to  take  every  pre- 
caution to  keep  on  the  through  track. 

ARTERIAL    DEGENERATION 

"A  man  is  only  as  old  as  his  arteries,"  is  a  saying 
among  doctors.  The  arteries  are  among  the  most 
important  organs  of  the  body,  and  are  among  the 


DISEASES  COMMON  TO  MIDDLE  LIFE  415 

first  to  show  the  changes  of  advancing  years. 
They  receive,  however,  but  Uttle  popular  attention. 
The  large  arteries  are  very  elastic,  the  arterial 
tissue  being  sometimes  known  as  vital  rubber. 
This  property  enables  them  to  dilate  with  each 
impulse  of  the  heart,  thus  reducing  the  shock  to 
the  organs  which  the  force-pump'  action  would 
give  were  the  blood  conveyed  in  rigid  tubes.  The 
small  arteries  are  encircled  with  muscle  fibers 
which  are  under  nerve  control.  They  are  con- 
tinually contracting  and  relaxing,  like'  the  pupil 
of  the  eye.  For  example,  when  food  enters  the 
stomach,  the  small  arteries  dilate,  and  an  extra 
supply  of  blood  goes  to  that  organ  to  carry  on 
digestion.  And  so  every  organ  and  tissue  receives 
a  larger  or  smaller  supply  of  blood  according  to 
its  changing  needs.  It  is  a  marvelous  and  delicate 
mechanism,  and  disturbance  of  its  action  is  neces- 
sarily followed  by  disease. 

The  first  of  the  retrograde  changes  which  mark 
the  decline  of  vital  power  is  seen  in  the  arteries. 
They  slowly  lose  their  elasticity  and  in  time  become 
stiff  and  rigid.  They  ma}^  undergo  degeneration 
in  local  areas  which  renders  them  weak  in  spots. 
There  is  no  definite  age  at  which  this  occurs.  In 
rare  instances  it  occurs  very  earh^  the  arteries  of 
a   man   at   thirty   being   like   those   of   a   man   at 


4i6  1107/   TO    KEEP   WELL 

seventy.  It  is  a  personal  and  sometimes  a  family 
characteristic.  This  peculiar  tendency  cannot  be 
explained  in  any  other  way  except  that  "in  the 
make-up  of  the  machine  bad  material  was  used 
for  the  tubing. "  To  a  lesser  degree,  this  tendency 
is  very  common.  Many  an  individual  of  fifty-five 
or  sixty  has  no  better  arteries  than  the  average 
at  seventy. 

If  the  arteries  become  very  stiff  and  Ijrittle,  they 
are  liable  to  break,  and  apoplexy  is  the  result. 
This  may  occur  in  any  organ,  but  the  term  is 
popularly  applied  to  cereljral  apoplexy,  in  which 
an  artery  of  the  brain  gives  way.  As  the  arteries 
grow  stiff  and  lose  their  power  of  expanding  and 
contracting,  the  heart  is  one  of  the  first  organs  to 
feel  it.  Owing  to  the  increased  effort  to  force 
the  blood  through  the  body,  it  becomes  enlarged 
and  undergoes  certain  changes.  The  kidneys  also 
feel  it  early,  and  arterial  degeneration  is  one  cause 
of  chronic  Bright's  disease.  The  liver  and  other 
organs  are  also  affected.  Arterial  degeneration — 
or  in  other  words,  old  age  of  the  arteries — is  one  of 
the  potent  causes  preventing  longevity. 

While  there  are  a  few  cases  of  premature  degen- 
eration of  the  arteries  due  to  personal  or  family 
peculiarities,  it  much  more  commonly  results  from 
the  abuse  of  good  vessels.     In  a  majority  of  cases 


DISEASES  COMMON  TO  MIDDLE  LIFE  417 

its  early  occurrence  is  due  to  causes  more  or  less 
preventable.  Among  the  first  of  these  are  gout 
and  syphilis,  which  always  involve  the  arteries  to 
a  greater  or  less  extent.  The  uric  acid  condition, 
which  is  so  much  more  common  in  this  country 
than  gout,  is  also  a  cause.  Next  to  these  are 
certain  toxic  elements,  of  which  alcohol  and  lead 
are  the  most  important.  Chronic  lead  poisoning 
is  alwa^'s  followed  by  disease  of  the  arteries,  but 
such  poisoning  is  very  rare.  Improper  diet  is  also 
an  exciting  cause.  ■  Excess  of  nitrogenous  food 
is  especially  injurious  to  the  arterial  system  in 
people  leading  a  sedentary  life  and  showing  a 
tendency  to  uric  acid.  Overeating  is  also  regarded 
by  most  authorities  as  a  cause,  one  reason  being 
that  the  arteries  become  distended. 

On  the  other  extreme  from  the  sedentary  workers 
are  those  who  do  severe  muscular  work.  Early 
arterial  degeneration  is  common  in  them.  The 
labourers  who  do  the  heaviest  kind  of  work  are 
not  usually  ver}^  long  lived.  The  same  is  true  of 
professional  athletes.  Violent  exertion  is  not 
conducive  to  health  and  long  life,  for  it  overtaxes 
the  arteries  as  well  as  the  heart.  Up  to  fifty  years 
of  age  men  are  more  subject  to  arterial  degenera- 
tion than  are  women,  but  after  that  age  it  is  equally 
common  in  both. 


4i8  HOW    TO    KEEP    WELL 

Arterial  degeneration  and  kidney  disease  are 
closely  associated,  but  it  is  often  difficult  to  decide 
which  is  the  primary  and  which  is  the  secondary 
condition.  There  is  a  form  of  arterial  disease 
which  may  come  on  without  previous  kidney 
affection  soon  after  forty  in  men  who  live  at  high 
tension  and  eat  and  drink  a  great  deal.  It  is  the 
result  of  the  strenuous  life  to  which  is  added 
strenuous  self-indulgence.  It  will  be  seen  that  the 
causes  of  arterial  disease  and  kidney  disease  are 
quite  similar.  The  measures  assigned  to  prevent 
one  are  effective  in  preventing  the  other.  In 
addition  to  the  usual  form  of  arterial  degeneration, 
fatty  degeneration  may  occur,  and  is  the  result  of 
the  same  causes  which  produce  fatty  degeneration 
elsewhere. 

GOUT 

While  gout  cannot  be  called  a  common  American 
disease,  it  is  far  from  rare.  It  is  a  disorder  of 
nutrition,  one  factor  of  which  is  excessive  forma- 
tion of  uric  acid.  It  is  due  to  imperfect  chemical 
changes  in  the  food  stuff  during  the  process  of 
assimilation,  combined  with  imperfect  elimination 
of  the  waste  products.  In  England,  fully  three- 
fourths  of  all  cases  of  gout  can  be  traced  to  gouty 
ancestry.  In  this  country,  while  the  hereditary 
element  is  strong,  it  is  not  as  marked.     The  trans- 


DISEASES  COMMON  TO  MIDDLE  LIFE  419 

mission  is  more  marked  from  the  male  side.  A 
grandson  may  inherit  gout  from  a  grandfather 
through  a  mother  who  has  never  exhibited  any 
gouty  manifestation.  When  the  hereditary  ten- 
dency is  very  strong,  evidences  of  the  disease  may 
appear  in  childhood.  It  rarely,  however,  develops 
before  the  thirtieth  year,  and  in  a  large  majority 
of  cases  the  first  manifestations  appear  before 
fifty.  After  hereditary,  the  most  potent  factors 
in  the  causation  of  gout  are  overdrinking  and 
overeating.  Fermented  liquors  favour  its  de- 
velopment more  than  do  spirits.  It  prevails 
most  extensively  in  countries  in  which  much  beer 
and  ale  are  consumed,  as  England  and  Germany. 
The  light  beers  used  in  this  country  are  less  liable 
to  produce  gout  than  is  heavy  ale,  porter  or  stout. 
Food  plays  a  role  almost  equal  in  importance  to 
that  of  alcohol.  Excessive  eating  without  bodily 
exercise  is  a  potent  cause.  The  popular  impres- 
sion that  gout  is  solely  a  disease  of  the  rich  is 
erroneous.  An  excessive  consumption  of  malt 
liquors,  when  combined  with  poor  food  and  bad 
hygiene,  may  readily  produce  gout  of  a  type  known 
in  England  as  "poor  man's  gout."  Still,  the  seden- 
tary life  is  a  very  potent  causative  factor. 

The  action  of  alcohol  in  producing  gout  is  thus 
positively  stated  by  Sir  Alfred  Garrod:     ''There 


420  HOW   TO    KEEP   WELL 

is  no  truth  in  medicine  better  established  than  the 
fact  that  the  use  of  fermented  Hquors  is  the  most 
powerful  of  all  predisposing  causes  of  gout;  nay, 
so  powerful  that  it  may  be  a  question  whether 
gout  would  ever  have  been  known  to  mankind 
had  such  beverages  not  been  indulged  in."  The 
different  forms  of  alcoholic  drink  are  not  equally 
potent  in  fostering  the  gouty  habit.  Port,  sherry, 
Madeira,  Burgundy,  champagne,  porter,  stout, 
and  heavy  ales  are  all  gouty  beverages.  They 
are  far  more  so  than  distilled  spirits  and  the  dry 
and  sour  wines.  Drunkards  and  old  topers  are 
rarely  gouty,  for  they  usually  drink  spirits  and 
are  not  high  livers.  It  is  those  against  whom 
nothing  can  be  said  as  regards  their  sobriety,  who 
become  gouty.  They  drink  beer  or  wine  with 
their  meals  and  "fare  sumptuously  every 
day." 

The  four  chief  causes  of  gout,  then,  are  (a) 
hereditary  tendency,  (b)  the  drinking  freely  of 
certain  malt  liquors  or  wines,  (c)  the  excessive 
eating  of  rich  food  of  nitrogenous  nature,  (d)  the 
sedentary  life.  Diet  and  certain  other  questions 
will  be  considered  under  the  uric  acid  tendency. 
When  the  hereditary  tendency  is  strong,  no  pre- 
cautions will  entirely  prevent  the  occurrence  of 
gout.     It  has  afflicted  some  of  the  greatest  of  men, 


DISEASES  COMMON  TO  MIDDLE  LIFE  421 

and  the  aphorism  is  true  that  "more  wise  men  than 
fools  are  victims  of  gout." 

LITHEMIA       (uric    ACID    CONDITION) 

Lithemia  is  a  condition  marked  by  an  excessive 
quantity  of  Hthic  acid,  or,  as  it  is  more  commonly 
called,  uric  acid.  It  is  closely  associated  with 
gout,  but  differs  from  that  disease  in  several 
important  features.  It  is  far  more  common  in 
this  country  than  gout.  It  has  been  well  described 
as  a  motley,  ill-defined  group  of  symptoms  showing 
disordered  nutrition.  Cases  are  seen  in  members 
of  gouty  families  who  may  never  themselves  suffer 
from  gout  itself.  It  is  seen  also  in  those  who  have 
lived  not  wisely  but  too  well.  They  are  mostly 
persons  who  eat  and  drink  largely,  live  sedentary 
lives,  and  have  yet  been  fortunate  enough  to 
escape  gout  itself.  In  these  irregular  cases  a 
variety  of  symptoms  occur.  Indigestion  is  very 
common,  there  being  a  particular  tendency  to 
attacks  of  so-called  biliousness.  There  is  a  ten- 
dency to  thickening  of  the  walls  of  the  arteries. 
This  may  lead  to  palpitation  and  more  serious 
difficulties.  Headache,  migraine,  neuralgia,  and 
cramps  in  the  legs  are  not  uncommon.  The  so- 
called  muscular  rheumatism  is  often  a  manifesta- 
tion of  uric  acid. 

There   has   been    a    strong   tendency   in   recent 


422  HOW   TO    KEEP   WELL 

years  to  attribute  all  manner  of  symptoms  to  uric 
acid,  which  have  no  relationship  to  it.  As  a 
matter  of  fact,  uric  acid  is  but  one  abnormal 
product  found  in  these  cases,  and  its  exact  part 
in  causing  these  symptoms  which  accompany  it 
is  somewhat  uncertain. 

The  preventive  management  of  gout  and 
lithemia  are  so  similar  that  the  two  may  be  con- 
sidered together.  It  must  be  both  hygienic  and 
dietetic.  For  those  who  have  inherited  a  tendency 
to  either,  or  have  shown  decided  symptoms,  there 
are  three  cardinal  rules:  live  temperately,  eat 
moderately,  and  abstain  from  alcohol.  An  open- 
air  life,  with  abundance  of  exercise,  is  very  helpful 
in  overcoming  inherent  tendency.  If  a  sedentary 
life  must  be  adopted,  the  importance  of  exercise 
is  particularly  great,  and  it  should  be  open-air 
e:iercise.  The  skin  should  be  kept  active,  and  this 
is  best  accomplished  in  the  cool  morning  bath  as 
directed  elsewhere.  If  the  reaction  from  this  bath 
is  not  good,  then  the  warm  evening  bath  should 
be  employed.  Turkish  baths  are  most  useful  for 
those  of  the  gouty  temperament.  The  clothing 
should  be  warm,  but  not  so  warm  as  to  cause  over- 
heating. Flannel  should  always  be  worn,  but  it 
may  be  of  thin  texture  in  summer.  When  we 
approach  the  subject  of  diet  for  those  inclined  to 


DISEASES  COMMON  TO  MIDDLE  LIFE  423 

gout  and  lithemia,  we  encounter  difficulties,  for 
practitioners  differ  considerably  in  their  views. 
The  personal  element  is  here  of  special  importance 
and  largely  accounts  for  diverging  opinions. 
"Nowhere  is  it  more  necessary  than  in  gout,"  says 
Sir  William  Roberts,  "to  consider  the  man  as  well 
as  the  ailment."  It  is  certainly  true  that  the  diet 
adapted  to  one  gouty  or  lithemic  man  is  not  always 
adapted  to  another.  When  the  hereditary  ten- 
dency is  strong  the  symptoms  will  sometimes 
appear  and  throw  discredit  upon  any  form  of 
treatment  and  diet.  When  the  tendency  is  slight, 
the  mere  reduction  of  the  quantity  of  aliment  is 
sometimes  sufficient. 

The  old  belief  that  all  nitrogenous  food  should 
be  prohibited  is  not  now  generally  accepted.  In 
this  class  of  food  is  included  meat  of  all  kinds, 
game,  fish,  and  eggs.  The  weight  of  opinion  now 
leads  to  the  use  of  a  modified  nitrogenous  diet, 
without  excess  in  starchy  or  saccharine  articles  of 
food.  Lithemiia  is  not  due  to  an  excess  of  nitrogen 
alone,  but  to  numerous  other  factors.  The  lithemic 
patient,  according  to  Doctor  A.  H.  Smith,  is  like 
a  spendthrift,  who  cannot  be  cured  by  keeping 
money  froKi  him.  He  must  be  educated  to  better 
habits.  As  the  spendthrift  will  pawn  his  clothes 
to  get  money,  so  the  system  will  pawn  the  tissues, 


424  HOW    TO    KEEP    WELL 

so  to  speak,  to  obtain  nitrogen.  It  is  not  necessary 
to  wholly  withhold  nitrogenous  food.  A  diet 
should  be  selected,  after  study  of  each  case,  which 
will  be  readily  digested  and  assimilated.  An 
excess  of  starch,  fat,  and  sugar  should  be  avoided, 
as  by  their  fermentation  they  produce  acids  which 
aggravate  the  disease.  Fats,  if  they  are  properly 
digested,  need  not  be  wholly  prohibited.  It  is 
better  to  give  moderately  of  dark  meat,  according 
to  Yeo,  one  of  the  best  English  authorities,  rather 
than  to  burden  the  digestive  organs  with  an  excess 
of  white  meat  and  other  foods  used  to  take  its 
place.  Green  vegetables,  fresh  fruits,  fish,  eggs, 
toasted  bread,  and  soups  or  meats  or  vegetables, 
are  especially  appropriate  articles  in  these  cases. 
Whether  milk  should  be  used  depends  largely 
upon  the  conditions  of  the  individual  case.  It 
should  not  be  used  if  it  causes  constipation  or  the 
so-called  bilious  conditions.  Water  should  be 
given  freely,  especially  alkaline  mineral  waters  like 
Vichy  and  lithia  water.  Hot  water  before  breakfast 
and  cold  water  between  meals  is  very  helpful.  The 
important  point  in  the  dietetic  management  is  to 
secure  a  wholesome  mixed  diet,  which  will  be 
readily  digested  and  assimilated  by  the  patient  for 
whom  it  was  designed.  •  It  should  include  a  little 
meat  and  other  nitrogenous  food,  while  the  sweet 


DISEASES  COMMON  TO  MIDDLE  LIFE  425 

and  starchy  elements  should  not  be  in  excess.  In 
addition  to  restricted  diet,  the  gouty  and  lithemic 
require  an  exceptionally  liberal  amount  of  exercise. 
This  cannot  be  too  strongly  insisted  upon. 

Mineral  water  is  beneficial  chiefly  because  of  the 
water  itself.  Among  the  resorts  best  suited  for 
gout  and  lithemia  are  Saratoga  and  the  Virginia 
Hot  Springs  in  the  United  States ;  Bath  and  Buxton 
in  England;  Aix-les-Bains  and  Contrexeville  in 
France;  Carlsbad  and  Homburg  in  Germany.  It 
is  certain  that  these  various  mineral  waters  are 
efficacious  more  because  of  the  amount  of  water 
taken  into  the  system  than  from  their  chemical 
properties.  At  these  various  resorts  the  waters 
are  taken  in  large  quantities  on  an  empty  stomach. 
In  addition  to  this  are  the  very  important  elements 
of  prescribed  diet  and  exercise,  freedom  from  care, 
regular   hours,    and  baths   properly   administered. 

There  are  mineral  springs  in  this  country  equal 
in  medicinal  value  to  any  in  the  Old  AVorld,  but  they 
are  under  no  adequate  supervision,  and  lack  the 
many  concomitants  which  render  such  places  as 
Carlsbad,  Homburg  and  Contrexeville  so  effica- 
cious. Moreover,  people  are  slow  to  take  advan- 
tage of  the  aid  that  is  available  in  American 
resorts.  Those  who  would  not  think  of  going  to 
a     Continental     resort     without     seeking    medical 


426  HOW   TO    KEEP   WELL 

advice,  consider  themselves  perfectly  capable  of 
selecting  an  American  watering  place  and  advising 
themselves  as  to  what  to  do  when  they  get  there. 
It  is  not  strange  that  American  health  resorts 
yield  less  favourable  results  than  do  the  European. 

DISEASES    OF    THE    LIVER 

The  diseases  of  the  liver  requiring  consideration 
here  are  but  three  in  number:  cirrhosis,  gall- 
stones, and  fatty  liver. 

Cirrhosis. —  This  disease,  sometimes  known  as 
"gin-drinker's  liver,"  consists  of  contraction  and 
hardening  of  the  liver,  with  consequent  oblitera- 
tion of  the  secreting  cells.  It  occurs  chiefly  in 
middle-aged  men,  being  about  four  times  as  com- 
mon in  them  as  in  women.  When  once  estab- 
lished it  is  incurable.  It  may  result  from  several 
causes,  but  the  excessive  use  of  distilled  spirits 
produces  many  more  cases  than  do  all  the  others 
combined.  As  the  sweet  wines  and  fermented 
liquors  cause  gout,  so  spirits  cause  cirrhosis. 
Alcohol  is  absorbed  from  the  stomach  and  expends 
its  first  force  upon  the  liver.  If  taken  into  an 
empty  stomach  its  absorption  is  very  rapid,  and  it 
enters  the  liver  undiluted.  The  early  morning 
dram  of  the  confirmed  toper  is  deadly  in  its  results. 
Wlien  a  man  finds  that  he  must  have  this  morning 
dram,  he  mav   write    himself   down    an    inebriate 


DISEASES  COMMON  TO  MIDDLE  LIFE  427 

(polite  name  for  drunkard),  whether  he  ever  gets 
drunk  or  not.  In  the  great  majority  of  cases 
cirrhosis  of  the  Hver  may  be  avoided  by  the  Hving 
of  a  sober  and  respectable  life. 

Gail-Stones. — These  occur  in  women  three  times 
as  often  as  in  men,  and  are  most  common  between 
thirty  and  sixty.  They  more  frequently  occur  in 
stout  than  in  thin  subjects,  and  in  those  who  lead 
a  quiet  or  sedentary  life.  The  use  of  sweet  and 
starchy  foods  predisposes  to  them.  The  conditions 
described  on  previous  pages  as  causing  lithemia 
are  also  active  in  causing  gall-stones.  Tight- 
lacing  is  an  undoubted  cause,  as  it  checks  the  flow 
of  the  bile.  Mental  depression,  constipation,  and 
dyspepsia  are  regarded  as  predisposing  causes. 
The  measures  for  the  prevention  of  gall-stones  are 
virtually  the  same  as  those  advised  for  lithemia. 

Fatty  Degeneration. — The  causes  of  this  condition 
are  the  same  as  those  which  result  in  the  fatty 
degeneration  of  other  organs.  The  subject  is  con- 
sidered in  the  following  section,  and  in  chapters 
on  the  sedentary  life  and  obesity. 

FATTY    DEGENERATION 

Fatty  degeneration  is  considered  in  many  of  its 
details  in  the  chapters  on  the  sedentary  life  and 
obesity.  It  is  not  simply  an  accumulation  of  fat 
about  an  organ  or  within  it,  but  it  is  the  conversion 


428  HOW   TO    KEEP   WELL 

of  the  substance  of  the  cells  themselves  into  fat. 
The  result  is  the  impairment  of  the  function  of 
the  organ  involved,  for  its  cells  are  destroyed. 
The  organs  most  frequently  involved  are  the 
arteries,  heart,  liver,  and  kidneys.  In  middle  life 
fatty  degeneration  results  chiefly  from  too  much 
aliment,  especially  of  the  starchy  and  saccharine 
class;  too  much  alcoholic  drink,  especially  sweet 
wines  and  fermented  liquors ;  and  too  little  exercise. 
It  may  be  caused  at  any  age  by  phosphorus  and 
arsenic  poisoning,  and  may  follow  diphtheria  and 
other  infections  and  other  wasting  diseases. 

As  I  had  occasion  in  several  places  to  point  out 
the  deleterious  effects  of  alcohol  when  taken  in 
health,  it  is  but  right  to  make  a  brief  statement 
regarding  its  use  in  disease.  The  great  majority 
of  medical  practitioners  agree  in  believing  that 
there  are  certain  acute  diseases,  like  diphtheria, 
pneumonia,  and  typhoid  fever,  in  which  judicious 
alcoholic  stimulation  is  sometimes  of  the  greatest 
value.  No  physician  believes  that  every  case 
should  receive  stimulants.  They  are  indicated 
only  in  certain  conditions  and  at  certain  stages. 
Their  use  requires  as  much  judgment  as  does  the 
use  of  opium  or  nux  vomica.  Because  these  drugs 
are  capable  of  doing  great  harm  if  taken  indis- 
criminately  in   health,   it   is   not   a   true   corollary 


DISEASES  COMMON  TO  MIDDLE  LIFE  429 

that  they  should  never  be  prescribed  in  acute 
illness.  It  is  true  that  there  are  a  few  physicians 
who  never  prescribe  alcohol,  and  there  is  cer- 
tainly a  growing  tendency  in  the  profession 
toward  restricting  its  use,  but  there  are  very 
few  experienced  practitioners  to-day  who  are 
willing  to  be  wholly  deprived  of  its  aid  in 
certain  emergencies  and  crises.  It  is  my  personal 
belief,  reached  after  years  of  conscientious  observa- 
tion, that  in  health  alcohol  is  never  necessary  and 
is  often  a  curse;  but  judiciously  prescribed  in 
disease  it  may  be  a  great  blessing  and  a  means  of 
saving  life. 

HEART    DISEASE 

The  heart  is  subject  to  many  forms  of  disease, 
some  being  common  to  early  life,  others  to  middle 
age.  Disease  of  the  valves  may  occur  at  any  age. 
It  usually  results  from  inflammation  caused  by 
the  poison  of  some  infectious  disease.  It  some- 
times complicates  scarlet  fever  and  diphtheria,  but 
rheumatism  causes  more  valvular  heart  disease 
than  do  all  other  causes  combined.  This  is  not 
true  of  chronic  or  muscular  rheumatism,  but  only 
of  the  acute  inflammatory  disease.  Such  rheu- 
matism is  especially  liable  to  involve  the  heart  in 
children.  In  many  cases  the  heart  accommodates 
itself  to  the  valvular  weakness  for  manv  years,  and 


430  HOW   TO    KEEP   WELL 

in  others  never  causes  any  trouble.  Most  of  the 
valvular  disease  of  later  life  dates  back  to  some 
rheumatic  attack  in  early  years.  In  children,  rheu- 
matism is  such  a  mild  disease  that  it  is  sometimes 
hardly  recognized  or  is  forgotten,  but  the  mildest 
attack  may  affect  the  heart.  Inflammation  of  the 
pericardium,  the  covering  membrane  of  the  heart, 
is  not  uncommon,  and  is  due  to  much  the  same 
causes  as  inflammation  of  the  interior  of  the  organ. 
There  is  virtually  but  one  way  of  preventing  val- 
vular heart  disease,  and  that  is  to  prevent  rheu- 
matism, a  subject  which  is  considered  in  another 
place. 

Disease  of  the  heart  muscle  is  not  infrequent  in 
middle  and  later  life.  Fatty  degeneration  is  most 
common,  but  there  are  other  forms  of  degenera- 
tion. These  conditions  are  often  very  difficult  of 
diagnosis,  for  in  many  cases  they  present  no  char- 
acteristic symptoms.  They  may  result,  however, 
in  sudden  failure  of  heart  power  upon  excessive  or 
abrupt  exertion.  Some  cases  of  sudden  death  are 
due  to  this  cause.  Gout  and  extreme  lithemia 
have  also  an  effect  upon  the  heart.  In  such  cases 
unexpected  heart  failure  may  occur  during  the 
course  of  acute  disease.  The  poison  of  diphtheria 
in  some  cases  causes  a  grave  form,  of  degeneration 
of    the   heart   muscle,     so   that    death    sometimes 


DISEASES  COMMON  TO  MIDDLE  LIFE  431 

results  suddenly  after  the  throat  symptoms  have 
disappeared.  The  importance  of  prolonged  rest 
in  such  cases  cannot  be  too  strongly  insisted  upon. 
There  are  certain  arteries  which  supply  the  heart 
itself  with  blood.  In  arterial  disease,  these  heart 
arteries  suffer,  and  their  rupture  or  obstruction 
is  a  cause  of  sudden  death.  These  various  degen- 
erative changes  of  the  heart  are  due  to  the  same 
causes  which  produce  such  changes  in  other  organs, 
and  their  prevention  is  considered  in  other  places. 

DIABETES 

•  Diabetes  is  a  constitutional  disease  in  which 
sugar  accumulates  in  the  blood  and  is  excreted  in 
the  urine.  It  is  not  a  disease  of  the  kidneys,  as  it 
is  frequently  believed.  The  kidneys  act  only  in 
removing  the  sugar  from  the  blood,  as  they  do  other 
foreign  substances.  It  is  much  less  common  in 
this  country  than  in  Europe.  It  occurs  with  par- 
ticular frequency  in  Paris.  While  it  cannot  be 
called  rare,  it  is  not  one  of  the  common  diseases. 
Although  no  age  is  wholly  exempt,  it  is  most  fre- 
quent between  fifty  and  sixty.  Men  are  more 
often  affected  than  women. 

Heredity  is  a  factor  in  its  causation,  as  might 
be  expected  from  its  frequent  association  with 
gout.  Worry  and  mental  shock  are  among  the 
more  prominent  causes.     High  tension  and  intense 


432  HOW   TO    KEEP   WELL 

methods  of  doing  business,  combined  with  a  seden- 
tary life,  are  apparently  capable  of  producing  it. 
In  some  cases,  the  same  causes  which  produce 
gout  seem  capable  of  producing  diabetes.  In  very 
many  cases  marked  obesity  precedes  the  onset  of 
the  diabetes,  and  seems  to  have  a  causative  relation 
to  it.  Whether  the  obesity  itself  be  the  cause,  or 
whether  the  two  conditions  be  produced  by  a 
common  cause,  is  not  certain.  Injuries  to  the 
head  and  spine  have  been  known  to  be  the  imme- 
diate cause  in  numerous  cases.  In  the  young, 
diabetes  is  much  more  rapid  and  fatal  than  it  is 
after  forty.  After  that  age  it  is  slow  in  its  prog- 
ress, and  is  sometimes  present  for  years.  If  the 
sugar  disappears  on  a  diet  free  from  sugar  and 
starch,  the  outlook  for  complete  relief  is  most 
favourable. 

It  is  evident  that  diabetes  is  not  as  readily 
preventable  as  some  of  the  diseases  that  have 
been  described.  Still  much  may  be  done  to  obviate 
its  occurrence.  When  there  is  any  suspicion  of 
tendency  to  it,  hereditary  or  otherwise,  the  use  of 
sweet  and  starchy  food  should  be  restricted,  and 
the  precautions  advised  for  the  prevention  of  gout 
should  be  observed.  Obesity  after  middle  life 
should  be  prevented  as  far  as  it  is  possible.  Sources 
of   unnecessary   worry    should   be    avoided.     The 


DISEASES  COMMON  TO  MIDDLE  LIFE  433 

surface  of  the  body  should  be  protected  from 
exposure  by  the  use  of  flannels,  and  the  skin  should 
be  stimulated  by  cool  bathing.  Turkish  baths  are 
distinctly  useful  as  a  preventive.  Exercise  is 
important,  and  an  occupation  should  be  selected 
if  possible  which  does  not  involve  sedentary 
living.  When  the  disease  has  manifested  itself, 
sugar  and  starches  should  be  eliminated  from  the 
diet,  but  the  details  of  management  must  be 
especially  arranged  for  each  case.  Here,  again, 
the  personal  element  is  very  strong.  It  is  the 
patient  who  requires  treatment  even  more  than 
the  disease. 

OBESITY 

After  forty,  there  is  apt  to  be  a  change  in  phy- 
sique, either  toward  spareness  or  stoutness.  Indi- 
viduals of  the  former  type  are  as  a  rule  the  healthier, 
and  enjoy  a  longer  lease  of  life.  There  are  two 
well-recognized  types  of  obesity,  the  plethoric  and 
the  anemic.  The  former  is  more  commonly  seen 
among  men,  and  is  a  condition  of  overnutrition. 
If  excessive,  it  may  be  followed  by  arterial  degen- 
erations and  kidney  trouble.  In  many  cases  the 
excess  of  fat  seems  but  slightly  detrimental,  and 
does  not  interfere  with  activity.  The  anemic 
type  is  more  often  found  in  women,  but  is  by  no 
means  confined  to  them.     There  is  paleness,  and 


434  HOW    TO    KEEP    WELL 

often  shortness  of  breath  upon  exertion.  The 
appetite  is  usually  small,  and  the  tendency  to  over- 
eat is  not  as  common  as  in  the  plethoric  type. 
There  is  prone  to  be  an  aversion  to  meat,  but  the 
love  of  sugar,  candy,  and  sweets  is  sometimes 
inordinate.  In  the  woman  of  this  type  irregu- 
larities are  the  rule,  and  nervous  disorders  are 
common. 

Tendency  to  obesity  is  hereditary  in  more  than 
50  per  cent,  of  cases.  When  the  tendency  is  strong, 
prevention  is  always  difficult  and  often  impossible. 
Classified  according  to  its  causes,  there  are  two 
types  of  obesity.  The  one  is  due  largely  to  over- 
eating, overdrinking,  and  lack  of  exercise.  The 
other  occurs  in  small  eaters  who  drink  no  alcohol. 
It  may  persist  on  the  most  meager  diet,  and  cannot 
be  entirely  removed  by  any  means  at  our  command. 
There  is  no  form  of  corpulence,  however,  which 
cannot  be  relieved  somewhat  by  proper  diet  and 
exercise,  and  in  many  persons  it  can  be  prevented 
entirely. 

The  methods  adopted  for  reducing  corpulence 
are  usually  exhibitions  of  zeal  without  knowledge. 
Stoutness  is  a  permanent  condition,  and  cannot 
be  overcome  by  spasmodic  and  intermittent 
efforts.  The  rational  plan  is  to  adopt  measures 
that    can    be    used    continuously.     The    "cures" 


DISEASES  COMMON  TO  MIDDLE  LIFE  435 

usually  resorted  to  are  so  radical  and  extreme 
that  no  one  can  or  ever  does  persevere  in  them. 
The  weight  must  be  reduced  so  many  pounds  a 
week  or  the  cure  is  considered  a  failure.  The 
"specialists"  who  reduce  corpulence  are  bound  to 
produce  a  striking  result  or  their  trade  will  fall 
off.  Having  accomplished  that  result,  they  leave 
the  patient  to  continue  it,  and  the  fault  is  placed  on 
him  if  he  does  not  do  so.  The  ability  of  the 
specialist  has  been  demonstrated.  But  the  methods 
are  such  that  no  rational  person  will  persist  in  them 
indefinitely.  Nine  out  of  ten  become  desperate, 
and  not  only  give  up  all  effort,  but  do  reckless 
things,  and  the  relapse  is  more  rapid  than  the  cure. 
I  have  no  cure  for  obesity  to  propose.  It  would 
not  be  within  the  scope  of  this  work,  even  if  such 
a  plan  were  desirable.  In  extreme  corpulence, 
when  rapid  reduction  is  indicated,  the  necessary 
measures  should  be  adapted  to  the  case  by  a 
competent  physician.  This  chapter  is  designed  to 
offer  some  advice  to  those  who  become  stout  at 
middle  life  but  not  excessively  obese.  To  secure  a 
permanent  result,  it  is  the  most  sensible  plan  to 
adopt  measures  of  living  which  can  be  adhered  to 
and  made  the  permanent  mode  of  life.  When  a 
decided  reduction  seems  desirable,  that  method  is 
best    which    acts    slowly    and    steadily.     Such    a 


436  HOW   TO    KEEP   WELL 

method  sometimes  shows  no  apparent  result  for 
the  first  two  or  tliree  weeks,  but  after  that  time 
a  steady  but  not  excessive  reduction  of  weight 
occurs. 

To  determine  the  best  mode  of  Hfe  for  this 
purpose,  we  may  learn  something  from  the  means 
adopted  for  rapid  reduction.  The  various  cures  in 
vogue  are  modifications  of  three  systems,  those  of 
Banting,  Oertel,  and  Ebstein.  Banting  was  a  fat 
undertaker  whose  weight  was  reduced  thirty- 
five  pounds  by  his  physician,  William  Harvey. 
He  was  so  much  pleased  that  he  wrote  a  letter 
in  1863,  "addressed  to  the  public,"  describing  his 
experience,  and  inadvertently  getting  his  name 
attached  to  the  method.  This  system  permits 
plenty  of  meat  and  alcoholic  drink,  reduces  the 
starch  and  sugar  moderately,  almost  completely 
forbids  fat,  and  places  no  limit  on  water.  It  is 
unsatisfactory  in  principle  and  practice.  The 
brain  and  nerves  normally  contain  more  fat  than 
any  other  tissues  of  the  body,  and  its  absence  from 
the  food  for  long  periods  is  injurious.  We  know 
to-day  that  fat  is  far  less  a  fat  producer  than  are 
sugar,  starch,  and  alcohol.  Banting's  method,  if 
persisted  in,  is  capable  of  doing  serious  harm. 
It  was  upon  this  method  that  the  so-called 
Salisbury  cure  was  based. 


DISEASES  COMMON  TO  MIDDLE.  LIFE  437 

The  main  feature  of  the  Oertel  method  is  the 
large  reduction  of  fluids.  Sugar  and  starch  are 
allowed  more  freely  than  in  the  Banting  method, 
and  much  more  fat.  The  Ebstein  method  cuts 
down  the  meat  and  greatly  reduces  the  sugar  and 
starch,  but  gives  fat  very  freely.  Weir  Mitchell 
advises  the  stopping  of  all  food  and  drink  except 
milk  and  eggs.  Of  them  he  gives  one  egg  and  eight 
ounces  of  milk  every  three  hours  for  three  weeks. 
The  dietary  is  then  slowly  enlarged,  but  is  markedly 
restricted.  This  affords  a  simple  and  usually 
effective  method  of  beginning  reduction. 

Strange  to  say,  each  of  these  radically  different 
systems  is  effective  in  largely  and  rapidly  reducing 
fat.  The  reason  is  not  far  to  seek.  They  effect 
their  result  through  wasting  of  the  body  by  virtual 
starvation.  The  Banting  system  cuts  down  the 
nutrition  value  of  the  food  to  one-third  that  of 
the  "normal  average  diet,"  and  the  other  two 
systems  to  about  one-half.  The  success  of  these 
systems  shows  that  the  prevention  of  corpulence 
does  not  depend  so  much  upon  the  reduction  of  a 
special  food  as  upon  a  reduction  of  all  the  food 
taken.  Hence,  the  first  important  rule  is  the 
avoidance  of  overeating.  Most  methods  of  rapid 
reduction  place  the  amount  of  food  too  low  to  be 
safe  for  prolonged  use.     It  should  not  be  supposed 


438  HOW   TO    KEEP   WELL 

that  a  judicious  selection  of  food  elements  may  not 
be  made  to  advantage.  The  sugars  and  starches 
should  be  decidedly  diminished,  and  the  fat  should 
also  be  reduced,  but  the  albuminoid  foods  may 
be  taken  freely.  If  the  person  is  a  large  water 
drinker,  as  many  stout  people  are,  the  amount 
of  fluid  should  also  be  diminished.  But  here  we 
are  often  confronted  with  a  dilemma.  A  diet  liberal 
in  meat  and  eggs,  with  a  small  amount  of  water,  is 
indicated,  on  the  one  hand,  for  the  relief  of  the 
corpulence.  But  on  the  other  hand,  such  a  diet 
predisposes  some  individuals  to  uric  acid  and 
irritation  of  the  kidneys.  Hence,  most  sensible 
systems  do  not  crowd  the  meat  too  far,  nor  restrict 
the  water  too  much.  As  a  rule,  water  should 
be  drunk  freely  between  meals.  It  should  bear 
some  relation  to  the  amount  of  meat  and  eggs 
eaten;  the  more  the  meat,  the  more  the  water. 

To  summarize,  we  may  say  that  the  diet  at 
middle  life,  when  there  is  a  tendency  to  stoutness, 
should  be  in  general  harmony  with  the  following 
outline,  it  being  understood  that  it  must  be  modified 
according  to  the  peculiar  tendencies  of  each 
individual : 

Exclude  entirely  fermented  liquors,  sweet  wines, 
puddings,  pastry,  and  rich  desserts. 

Take    in    very  limited  quantity  sugar  (enough 


DISEASES  COMMON  TO  MIDDLE  LIFE  439 

to  make  the  food  palatable),  potatoes,  the  starchy 
vegetables  which  grow  underground,  thick  soups, 
and  milk. 

Take  in  small  quantities  farinaceous  and  starchy 
foods,  cereals,  bread  (best  in  form  of  thin  toast), 
and  clear  soups. 

The  following  may  be  taken  more  freely,  but 
still  in  moderation:  Meat  of  all  kinds  once  a  day, 
eggs  once  a  day,  fat— especially  in  the  form  of 
butter. 

Still  more  freely  may  be  taken  green  vegetables, 
saladS)  fruits,  fresh  fish,  and  fowl.  These  should 
be  made  an  important  part  of  the  diet,  especially 
in  summer. 

Tea  may  be  used,  but  coffee  and  chocolate 
should  be  restricted,  but  not  necessarily  excluded. 
Tobacco  should  be  vised  with  great  moderation. 
Little  fluid  should  be  taken  with  the  meals, 
but  water  may  be  taken  between  meals  as  already 
specified.  Milk  should  be  taken  sparingly,  unless 
it  is  used  alone  as  a  special  mode  of  diet. 

It  should  be  fully  understood  that  exercise  is  as 
important  as  food  in  keeping  down  flesh.  For 
this  particular  purpose  walking  is  of  especial  value. 
Golf,  which  involves  so  much  muscular  activity, 
in  addition  to  walking,  is  one  of  the  most  effective 
fat-reducing    exercises    known.     Tennis     and     all 


440  HOW    TO    KEEP    WELL 

outdoor  sports  are  also   serviceable.     Daily  exer- 
cise on  foot  is  a  necessary  part  of  every  system. 

CANCER 

The  increase  in  the  occurrence  of  cancer  is  one 
of  the  most'  noteworthy  features  of  disease  of 
recent  times.  It  is  widespread,  and  is  not  con- 
fined to  a  single  country.  In  England,  the  occur- 
rence per  million  of  inhabitants  during  the  past 
four  decades  has  been  respectively  384,  468,  598, 
and  829.  An  increase  is  shown  in  Germany  and 
Russia,  while  in  Switzerland  it  has  been  particularly 
marked.  In  the  Netherlands,  in  twenty-four 
years,  there  has  been  an  increase  in  cancer  of  eighty 
per  cent.  An  increase  is  shown  in  ^.Imost  every 
State  of  the  American  Union.  The  United  States 
census  shows  that  in  1850  there  was  one  death 
from  cancer  to  156  from  other  causes.  This 
ratio  increased  in  each  report  until  in  1900  it  was 
one  to  thirty-five.  These  changes  are  not  quite  as 
great  as  they  may  seem.  With  increase  in  medical 
knowledge  and  diagnostic  skill,  many  cases  are 
now  discovered  which  would  not  have  been  recog- 
nized fifty  years  ago.  This  is  especially  true  of 
internal  cancers,  which  form  a  large  percentage 
of  the  whole  number.  It  is  these,  in  fact,  which 
have  shown  the  most  decided  increase.  But 
making  every  allowance  upon  such  grounds,  the 


DISEASES  COMMON  TO  MIDDLE  LIFE  441 

fact  remains  that  there  has  been  a  great  increase 
in  the  frequency  of  this  disease. 

To  few  other  diseases  has  more  earnest  study 
been  given.  A  vast  amount  of  knowledge  has 
been  accumtilated,  and  yet  there  are  few  diseases 
upon  which  so  httle  can  be  said  regarding  actual 
causation.  Innumerable  theories  have  been  pro- 
posed, but  have  one  and  all  been  found  wanting. 
One  of  the  more  recent  theories  attributes  the  dis- 
ease to  the  increased  amount  of  meat  consumed. 
Reiche,  of  Hamburg,  has  recently  shown,  however, 
that  it  occurs  as  often  in  the  poor  and  ill-fed  parts 
of  the  town  as  in  the  rich  and  prosperous.  It  pre- 
vails in  European  countries  where  very  little  meat 
is  eaten.  This  is  an  example  of  the  many  theories 
which  have  been  disproved  upon  investigation. 
The  theory  that  the  disease  is  produced  by  certain 
parasites  has  been  strongly  held,  but  lacks  con- 
firmation. The  ver}^  recent  report  of  the  cancer 
committee  of  the  Harvard  Medical  School,  while 
it  does  not  completely  disprove  this  theory,  throws 
the  gravest  doubts  upon  it.  The  bacterial  origin 
of  cancer,  which  has  also  been  urged,  has  not 
received  confirmation.  At  present  it  seems  more 
probable  that  the  origin  of  the  disease  will  be 
discovered  by  the  aid  of  physiological  and  patho- 
logical chemistry.     Much  is  known  of  the  pathology 


442  HOW   TO    KEEP   WELL 

of  cancer — that  is,  of  its  physical  nature  and  method 
of  growth.  It  has  been  called  a  condition  of  cell 
anarchy,  or  cell  revolution.  It  consists  of  over-, 
active  and  wrong  methods  of  growth  of  the  cells. 
These  are  well  understood.  It  is  not  the  method 
of  diseased  growth  regarding  which  we  are  still 
in  the  dark,  but  the  agency  which  starts  it  into 
action.  Prolonged  or  often-repeated  irritation 
of  a  part,  particularly  if  it  has  been  the  seat  of 
injury  or  inflammation,  is  a  predisposing  cause, 
and  possibly  an  exciting  cause.  Hence  lacerations 
and  old  sores  show  more  tendency  than  does 
normal  tissue  to  be  affected.  While  few  of  them 
ever  become  cancerous,  still  their  proper  treat- 
ment is  one  of  the  means  of  preventing  such  a 
result. 

It  will  be  seen  that,  with  our  present  knowledge, 
no  positive  rules  can  be  given  for  the  prevention  of 
cancer.  The  observance  of  the  following  rule, 
however,  will  do  much  to  reduce  its  mortality: 
No  abnormal  growth  in  any  part  of  the  body 
should  ever  be  regarded  as  unimportant.  The 
best  medical  advice  available  should  be  sought 
early.  The  patient  need  not  be  alarmed  if  the 
doctor  should  call  it  a  tumour.  People  often  sup- 
pose that  a  tumour  and  cancer  are  the  same.  The 
surgeon  calls  every  growth  a  tumour,  but  only  a 


DISEASES  COMMON  TO  MIDDLE  LIFE  443 

small  proportion  of  the  tumours  he  sees  are  can- 
cerous. Tumours  are  of  two  classes,  benign  and 
malignant.  The  former  are  much  the  rnore 
common,  and  comprise  swollen  glands,  fatty, 
fibroid,  and  many  other  tumours.  The  term 
"  cancer  "  is  a  popular  name  which  covers  several 
forms  of  disease.  On  the  one  extreme  is  the 
very  grave  condition  known  as  hard  cancer;  on 
the  other  are  several  forms  of  growth  on  the 
border  line  between  the  benign  and  malignant. 
The  one  tends  to  recur  even  when  removed  early. 
The  other,  if  left  in  the  body,  is  prone  to  take  on  a 
malignant  character,  but  if  removed  shows  no 
tendency  to  recur.  Between  these  extremes  are 
other  forms,  malignant  and  capable  of  doing 
serious  harm  if  not  removed,  and  showing  but 
slight  tendency  to  recur. 

The  semi-malignant  tumours  often  look  as  bad  as 
the  malignant  ones  do  in  their  early  stages.  It  is 
upon  these  semi-malignant  growths  that  the 
cancer  curers  flourish.  Their  cures  are  effected 
upon  the  growths  which  have  but  little  tendency 
to  recur.  They  make  a  strong  point  of  curing 
without  operation.  When  their  work  is  effective, 
they  mostly  employ  caustics,  usually  in  the  form 
of  a  paste.  The  celebrated  Vienna  paste,  for 
example,  consists  of  equal  parts  of  caustic  potash 


444  HOW   TO    KEEP   WELL 

and  quicklime  moistened  with  alcohol.  Many 
a  deluded  sufferer  has  endured  the  most  dreadful 
pain  for  days  rather  than  undergo  an  operation. 
There  is  not  a  paste,  or  caustic,  or  method  of 
treatment  in  use,  which  is  not  known  to  surgeons. 
Most  of  them,  in  fact,  have  been  stolen  from 
regular  practitioners.  While  I  was  on  the  staff  of 
the  Skin  and  Cancer  Hospital,  extended  observa- 
tions were  made  upon  the  use  of  these  various 
pastes.  Some  of  them  do  excellent  work  in  super- 
ficial growths  and  mild  conditions.  The  cases 
are  limited,  however,  in  which  they  constitute  the 
best  treatment.  In  many  cases  they  are  futile  if 
the  growth  is  malignant.  It  is  simply  silly  to  say 
that  "surgeons  operate  because  they  like  to  use 
the  knife."  That  expression,  "the  knife,"  is  one 
of  the  most  effective  weapons  of  the  quack.  Sur- 
geons use  pastes  and  similar  methods  in  some 
cases  of  cancer,  but  they  operate  in  most  cases, 
because  in  that  way  they  get  the  best  results. 
From  the  standpoint  of  the  patient,  the  best 
results  are  very  desirable  results  to  secure. 

Early  removal  will  save  many  lives,  even  when 
the  growth  is  of  the  more  serious  types.  Delay 
is  dangerous.  There  is  no  form  of  internal  medi- 
cation which  will  check  the  growth  of  true  cancer. 
This  statement  cannot  be  made  in  a  too  positive 


DISEASES  COMMON  TO  MIDDLE  LIFE  445 

manner.  ■  Temporizing  with  such  things  as  clover 
tea  or  sarsaparilla  is  taking  desperate  chances. 
If  the  disease  be  a  true  mahgnant  one,  it  will  go  on 
and  in  time  involve  the  neighbouring  glands,  and 
finally,  when  operation  is  decided  upon,  it  will 
be  too  late.  Conservatism  is  a  quality  of  the 
highest  value  in  medical  and  surgical  practice. 
There  are  many  places  in  which  it  is  the  course  of 
wisdom  to  watch  and  await  developments.  There 
are  other  places  where  true  conservatism  leads  to 
prompt  action  and  where  rashness  consists  in 
delay.  This  is  true  in  the  case  of  malignant 
growths,  or  of  those  whose  character  cannot  be 
certainly  determined  but  is  open  to  reasonable 
suspicion. 

Inci-easing  experience  is  adding  to  the  belief 
that  in  the  Roentgen  ray  we  have  a  potent  agent 
for  the  treatment  of  cancer,  but  there  is  no  evi- 
dence yet  at  hand  to  prove  it  a  cure-all.  It  should 
not  be  employed  to  the  exclusion  of  operation  in 
operable  cases.  In  the  most  recent  expert  article 
on  the  treatment  of  cancer  at  the  time  of  this 
writing,  the  conclusion  is  drawn  that  the  best 
interest  of  the  patient  is  served  by  early  diagnosis, 
early  radical  removal  by  surgical  methods,  and 
subsequent  treatment  of  the  infected  area  by  the 
Roentgen  method. 


446  HOW   TO    KEEP    WELL 

CONSTIPATION 

This  troublesome  disorder  is  not  limited  to  middle 
life,  though  it  is  especially  common  at  that  time. 
It  is  considered  here,  however,  as  no  other  place 
seems  more  suitable.  It  is  a  cause  of  many  ills 
from  which  all  sorts  and  conditions  of  people 
suffer,  and  its  removal  is  prerequisite  to  their 
cure.  Dyspepsia  and  indigestion  in  all  its  forms 
can  rarely  be  rectified  as  long  as  constipation 
exists.  All  the  diseases  considered  in  this  chapter 
are  aggravated  by  it,  and  nearly  every  condition 
of  ill  health  is  made  worse  by  its  presence.  A 
large  number  of  proprietary  and  patent  medicines 
derive  whatever  beneficial  influence  they  possess 
from  the  fact  that  they  are  laxative  in  their  action. 

The  causes  of  constipation  are  very  numerous, 
and  the  subject  is  a  complicated  and  difficult  one. 
I  have  in  my  library  a  quarto  volume  of  500  pages 
wholly  devoted  to  constipation  in  children  and 
adults.  It  is  by  no  means  the  simple  matter  that 
the  makers  of  liver  pills  would  lead  one  to  believe. 
The  first  cause  to  be  considered  is  constitutional 
proclivity,  either  inherited  or  inherent,  and  is 
characteristic  of  some  families.  It  may  be  due  to 
weakness  of  the  muscles  or  other  organic  defects ; 
often  the  result  of  some  gastro-intestinal  disease 
of  early  life.     In  such  cases  prevention  is  always 


DISEASES  COMMON  TO  MIDDLE  LIFE  447 

difficult,  and  there  are  some  which  cannot  be 
overcome  by  diet  and  exercise  alone.  The  seden- 
tary life  is  another  important  cause  of  constipation, 
and  it  is  necessary  for  most  of  those  who  live  such 
lives  to  take  measures  against  it,  the  chief  of  which 
are  diet  and  exercise.  Improper  diet  is  a  potent 
cause,  -  and  is  commonly  associated  with  most  of 
the  other  causes.  A  diet  consisting  of  concentrated 
foods,  like  meat,  eggs,  and  milk,  is  constipating. 
These  foods,  being  largely  digested  in  the  stomach, 
are  soon  absorbed,  and  leave  but  little  residue. 
Astringent  articles,  like  tea,  claret,  and  brandy, 
check  bowel  action.  Habitualty  small  eaters  are 
often  of  constipated  habit,  and  the  same  is  some- 
times true  of  those  who  overeat  of  coarse  and 
indigestible  food.  Irregularity  of  eating,  and 
great  variations  in  the  amount  of  food  taken,  by 
deranging  digestion,  tend  to  produce  constipa- 
tion. A  fourth  important  cause  is  insufficient 
fluid.  Occasionally  the  free  drinking  of  water 
will  produce  a  brilliant  result  in  relieving  consti- 
pation, but  the  number  of  such  cases  is  not  large. 
It  will  usually,  however,  be  an  aid  to  other  meas- 
ures. Irregularity  of  habits  and  neglect  of  the 
calls  of  nature  cause  much  constipation.  So 
important  is  regularity  that  other  means  are,  as  a 
rule,    ineffective    if    the    habit    is    not    formed    of 


448  HOW   TO    KEEP   WELL 

attempting  to  relieve  the  bowels  every  day  at  the 
same  hour.  The  habitual  use  of  medicine  is  a  bad 
habit,  and  the  cause  of  the  very  condition  it  is 
designed  to  relieve.  Constipation  is  a  common 
accompaniment  of  certain  diseases  of  the 
liver  and  stomach,  and  also  of  anemia  and 
all  forms  of  prostration  and  reduced  physical 
strength. 

Constipation  so  commonly  accompanies  other 
conditions  that  diet  can  rarely  be  prescribed  for 
it  without  also  considering  them.  In  general 
terms  the  diet  should  contain  but  a  small  proportion 
of  meat  and  other  concentrated  forms  of  food, 
but  should  consist  of  fruit,  vegetables,  and  cereals. 
As  in  arranging  a  diet  for  obesity,  one  should  be 
adopted  that  can  be  adhered  to.  A  tendency  to 
constipation  is  continuous  and  persistent,  and  must 
be  met  by  continuous  and  persistent  measures. 
Two  errors  are  common.  The  first  is  reliance 
on  a  single  measure — a  single  article  of  diet,  a 
single  mechanical  measure,  or  a  single  drug.  No 
one  of  these  is  in  itself  sufficient  if  the  case  is 
obstinate.  The  diet  must  be  corrected,  and  the 
attack  must  be  made  from  several  points  at  once. 
The  second  error  is  the  attempt  to  correct  a  con- 
tinuous and  persistent  condition  by  intermittent 
and  spasmodic  management. 


DISEASES  COMMON  TO  MIDDLE  LIFE  449 

The  following  are  among  the  laxative  articles  of 
food,  and  are  suitable  for  the  constipated.  It 
must  be  understood  that  the  eating  of  one  or  two. 
of  them  will  not  overcome  the  trouble.  The  diet 
must  usually  be  wholly  remodeled  and  made  to 
contain  a  large  proportion  of  the  following  articles : 
Green  vegetables  and  salads  of  all  kinds;  cereals, 
especially  oatmeal,  hominy,  and  farina;  bread 
made  of  cornmeal,  whole  wheat,  or  Graham  flour; 
raw  fruits,  especially  oranges,  figs,  prunes,  apples, 
peaches,  berries,  and  grapes;  cooked  fruits,  espe- 
cially baked  apples  and  stewed  prunes ;  light  soups 
and  broths;  fish  of  most  kinds  simply  cooked,  and 
fish  preserved  in  oil;  poultry  and  game  in  modera- 
tion; sugar,  honey,  and  molasses,  care  being  taken 
not  to  take  enough  to  disturb  the  digestion ;  butter 
and  olive  oil.  The  following  articles  should  be 
taken  sparingly,  but  it  is  rarely  necessary  to  pro- 
hibit them  entirely:  eggs  (especially  hard  boiled), 
meat,  salt  fish,  liver,  milk,  cheese,  nuts,  peas,  beans, 
rice,  wheat  foods,  strong  tea,  and  sour  wines. 

The  exercise  best  adapted  to  those  of  constipated 
tendency  is  walking,  or  playing  golf  or  tennis. 
Certain  exercises  designed  to  strengthen  the 
muscles  of  the  abdomen  are  also  useful.  Rubbing 
or  kneading  the  abdomen  is  a  helpful  measure,  while 
massage  is  very  efficacious  when  the  tendency  is 


450  HOW   TO    KEEP    WELL 

strong.  In  that  case,  the  trouble  can  only  be 
prevented  by  the  systematic  and  persistent  use  of 
all  the  measures  available — diet,  exercise,  local 
measures,  and  regular  habits. 


CHAPTER   XVII 
The  Sedentary  Life 

It  has  been  said  that  the  present  generation  is 
the  first  in  all  history  that  has  been  sedentary. 
Certain  it  is  that  the  sedentary  class  has  increased 
during  the  past  quarter  of  a  century  to  a  vast 
army.  By  a  strict  definition,  the  term  applies  to 
those  who  sit  at  their  work.  The  conditions  of 
modern  business,  however,  require  many  workers 
to  stand,  but  in  so  limited  an  area  that  they  may 
be  classed  without  impropriety  as  sedentary 
workers.  There  are  present  the  important  factors 
of  indoor  life,  more  or  less  imperfect  heating,  light- 
ing, and  ventilation,  and  lack  of  effective  exercise. 
The  only  difference  is  that  of  bodily  position,  the 
exercise  of  the  one  who  stands  being  but  little 
more  than  that  of  the  one  who  sits. 

Upon  no  other  individual  does  our  modern 
civilization  place  so  heavy  a  burden  as  upon  him 
who  leads  the  sedentary  life.  It  is  the  life  farthest 
removed  from  the  normal.  Those  who  have  been 
reared  into  it  acquire  at  the  same  time  habits  of 

451 


452  HOW   TO    KEEP    WELL 

life  more  or  less  adapted  to  the  condition.  It  is 
those  who  come  suddenly  into  it  who  are  the  worst 
sufferers.  They  rarely  adapt  themselves  to  the 
new  conditions  by  a  change  of  habits.  The  country 
boys  who  come  into  the  cities  in  such  numbers 
have  led  a  life  diametrically  opposite  to  the  one 
they  are  entering.  Even  if  they  have  been  reared 
in  a  village  or  small  city,  they  have  lived  a  life  of 
comparative  quiet,  and  have  spent  much  of  their 
time  in  the  open  air.  They  come  into  noise  and 
excitement,  live  in  small  rooms  in  crowded  locali- 
ties, eat  more  meat  than  they  were  accustomed  to 
before,  and  spend  their  hours  of  labour  in  close 
rooms,  and  get  little  bodily  exercise.  It  is  not 
strange  that  there  are  so  many  failures  and  break- 
downs and  smash-ups  among  young  men  of  this 
class.  If  they  are  sturdy  and  vigorous,  they  can 
tolerate  the  life  sedentary  with  overfeeding  and 
lack  of  exercise.  They  are  particularly  liable  to 
suffer  from  its  results,  however,  in  later  life.  The 
error  of  overeating  is  more  frequent  among 
sedentary  workers  than  among  any  other  class  of 
people. 

The  results  of  overfeeding,  combined  with  the 
sedentary  life,  are  admirably  illustrated  by  the 
goose  of  Strasburg.  This  bird  is  kept  in  a  close, 
warm  place,  without  the  possibility  of  exercise,  and 


THE   SEDENTARY   LIFE  453 

is  forcibly  fed  on  enormous  quantities  of  nourishing 
diet,  chiefly  milk  and  barley.  It  rapidly  becomes 
corpulent  and  heavy.  Its  liver  becomes  larger 
and  larger,  and  finally  attains  a  state  of  fatty  degen- 
eration which  renders  it  available  for  that  luxury 
of  luxuries,  pate  de  joie  gras.  We  thus  have  in  the 
goose  of  Strasburg  the  most  perfect  type  of  the 
sedentary  liver.  But  as  Thompson  aptly  remarks, 
we  do  not  have  to  go  to  Strasburg  to  see  excellent 
examples  of  the  same  type.  We  constantly  see 
those  who  spend  their  lives  in  close,  warm  places, 
with  little  exercise,  putting  into  their  stomachs 
enormous  and  unnecessary  quantities  of  fat- 
producing  aliment.  Fatty  degenerations,  not  of 
the  liver  "alone,  but  of  the  heart  and  various  tissues 
of  the  body,  are  becoming  more  common.  This 
form  of  disease  is  one  of  the  few  that  has 
increased  during  the  past  two  decades.  It  is  due 
largely  to  three  causes:  increase  in  the  number 
of  sedentary  workers,  failure  to  modify  the  habits 
when  such  a  life  is  adopted,  and  the  drinking  of 
malt  liquors.  Large  numbers  of  these  workers 
take  the  food  adapted  to  the  manual  labourer. 
They  eat  too  much  meat,  drink  too  much  beer  and 
coffee,  and  use  too  much  tobacco. 

As   explained   in   the   chapter   on   regimen,   the 
assimilation    of  the  food  to  the  uses  of  the  body 


454  HOW   TO    KEEP   WELL 

after  it  has  passed  from  the  digestive  organs  is  of 
vital  importance.  Certain  food  may  be  improper 
for  an  individual,  even  if  he  digests  it  perfectly, 
for  he  may  not  be  able  to  assimilate  it.  "  His  food 
does  him  no  good,"  is  a  common  expression. 
Muscular  action  is  necessary  for  the  assimilation  of 
some  kinds  of  food.  It  is  manifestly  absurd, 
therefore,  for  those  who  take  little  exercise  to  con- 
sume large  quantities  of  such  food.  A  popular 
method  of  describing  this  form  of  non-assimilation 
is  to  say  that  a  food  is  "clogging"  or  "bilious." 
Meat  and  beer  are  two  elements  to  which  these 
terms  are  particularly  applicable.  Coffee,  as 
before  described,  checks  tissue  activity,  precisely 
the  thing  that  exercise  is  designed  to  increase. 
The  same  is  to  a  certain  extent  the  action  of 
tobacco.  If  exercise  is  a  part  of  the  daily  life,  then 
a  food  may  be  taken  which  will  support  muscular 
activity,  and  a  drink,  perhaps,  which  will  check 
tissue  waste.  But  why  put  such  food  into  the 
body  and  then  consume  valuable  time  in  exercising 
it  out  ?  A  certain  amount  of  exercise  is  necessary 
to  keep  the  muscles  and  organs  in  proper  condition. 
We  cannot  avoid  taking  some  food  that  demands 
muscular  activity  for  assimilation  and  elimination, 
but  a  man  who  finds  it  necessary  to  take  an  exces- 
sive amount  of  exercise  in  order  to  keep  himself 


THE    SEDENTARY    LIFE  455 

in  reasonable  condition  may  be  certain  that  there 
is  something  wrong  with  his  diet. 

It  is  a  fundamental  proposition  that  the  "  intake" 
should  bear  some  relation  to  the  "outgo. "  If  the 
outgo  has  to  be  forced  too  vigorously,  in  the 
absence  of  diseased  organs,  it  indicates  that  the 
intake  is  too  large.  Is  it  not  wiser  to  reduce  the 
intake  rather  than  expend  so  much  time  and  labour 
in  increasing  the  outgo  ?  This  has  been  written 
under  the  supposition  that  the  individual  sees  to 
it  that  the  outgo  is  kept  at  par  with  the  intake  by 
means  of  vigorous  exercise.  But  suppose  he  does 
not  do  this  ?  What  happens  when  the  intake  is 
allowed  to  become  comparatively  excessive  ?  It 
requires  no  physician  to  answer.  Something  must 
clog  up.  Sometimes  the  first  effect  is  felt  by  the 
digestive  organs,  and  the  individual  becomes  thin, 
irritable,  and  dyspeptic.  In  other  cases,  fat  is 
stored  up,  and  the  person  becomes  corpulent.  In 
others,  the  liver  becomes  sluggish  and  fatty.  The 
kidneys  are  irritated  in  attempting  to  do  too 
much  work  in  eliminating  the  excessive  waste 
products.  The  individual  has  "bilious  attacks," 
uric  acid  or  gouty  attacks,  sick  headaches,  migraine, 
muscular  rheumatism,  or  any  one  of  a  score  of 
other  symptoms.  He  becomes  heavy  and  lazy, 
and  feels  that  he  is  capable  of  less  mental  exertion. 


456  HOW   TO    KEEP   WELL 

There  are  two  requisites  for  such  a  case.  Unless 
they  are  fulfilled,  no  treatment  will  avail  to  give 
permanent  relief.  These  are  less  food  and  more 
exercise.  Exercise  is  the  only  way  of  getting  rid 
of  the  "unspent  food  which  saturates  the  system.  " 

It  should  be  understood  that  the  preceding 
remarks  apply  but  partially  to  that  type  which 
naturally  tends  to  become  very  stout.  Many 
individuals  acquire  fat  on  the  most  meager  diet. 
On  an  improper  diet  it  will  accumulate  almost 
without  limit.  In  such  cases  the  fat  is  laid  on  the 
body  and  between  the,  organs,  being  in  a  certain 
sense  superficial.  Strict  dieting  and  active  exer- 
cise will  readily  reduce  it.  There  is  often  no 
tendency  to  fatty  degeneration  of  the  organs,  which 
is  a  deep-seated  process,  in  which  the  elements 
composing  the  organs  become  degenerated  and 
infiltrated  with  fat.  It  is  largely  the  result  of 
vicious  diet  and  habits,  and  when  it  has  occurred 
can  be  but  partially  relieved.  Stoutness  does  not 
necessarily  mean  fatty  degeneration. 

There  is,  on  the  other  extreme,  a  certain  thin 
type  which  never  accumulates  fat.  Attempts  to 
increase  the  weight  by  diet,  change  of  air,  or 
exercise  will  add  a  few  pounds,  after  which  no 
effort  will  add  another  ounce.  In  the  first  type 
mentioned  there  is  an  unnecessarily  large  amount 


THE   SEDENTARY   LIFE  457 

of  reserve  raaterial.  While  it  is  often  burdensome, 
the  individual  may  be  free  in  action  and  perfectly 
clear  of  head,  unlike  the  one  who  becomes  corpu- 
lent from  bad  diet  and  is  liable  to  fatty  degenera- 
tions. The  thin  type,  often  known  as  the  motive 
temperament,  is  frequently  all  muscle  and  capable 
of  enormous  labour.  There  is  lack,  however,  of 
reserve  material,  and  such  an  individual  must  be 
fed  regularly  or  the  motive  power  fails.  This  type 
is  inclined  to  tolerate  the  sedentary  life  better  than 
does  the  obese  type. 

In  returning  more  explicity  to  the  subject  of 
diet,  consider  the  differences  in  the  life  of  the 
manual  labourer  and  the  sedentary  worker.  For 
at  least  eight  hours  each  day  the  first  is  engaged  in 
vigorous  physical  exercise,  usually  in  the  open  air. 
He  swings  a  sledge,  uses  a  shovel,  or  carries  heavy 
weights.  Another  class  of  manual  labourers  may 
work  less  vigorously,  but  the  worker  is  not  idle 
for  hours  together.  The  sedentary  worker  sits 
at  a  desk  or  a  machine  within  doors  or  moves  about 
an  office.  He  gets  his  luncheon  in  the  same  build- 
ing, or  walks  a  few  blocks  for  it,  and  morning  and 
night  he  may  take  fifteen  or  twenty  minutes' 
"exercise"  in  his  room.  Altogether,  he  may  be 
able  to  perform  as  much  physical  labour  in  a  fort- 
night as  an  Italian  labourer  in  the  subway  does  in  a 


458  HOW   TO    KEEP   WELL 

day.  His  aliment,  however,  may  be  depended  upon 
to  be  about  equal  each  day  to  that  of  the  subway 
digger.  It  should,  however,  be  different  in  quality 
and  smaller  in  amount.  It  should  be  nourishing, 
and  not  mere  milk  and  water.  If  much  brain- 
work  is  done,  the  diet  should  be  liberal,  for  such 
work  uses  up  aliment  as  well  as  does  muscular 
labour.  "Cereal  foods,"  says  Thompson,  "and 
well  made  bread  in  variety,  and  vegetable  produce, 
including  fruits,  should  form  a  fair  portion  of  the 
diet,  with  the  addition  of  eggs  and  milk  and  little 
of  other  animal  food  than  fish,  fowl,  and  game. 
On  such  a  dietary,  and  without  alcoholic  stimulants, 
thousands  of  sedentary  workers  may  enjoy  with 
very  little  exercise  far  better  health  and  more 
strength  than  at  present  they  experience  on  meat 
and  heavy  puddings,  beer,  baker's  bread,  and 
cheese.  Of  course,  there  are  workers  whose  habits 
cannot  be  strictly  described  as  sedentary,  who 
occupy  a  middle  place.  For  such,  some  corre- 
sponding modification  of  the  dietary  is  naturally 
appropriate.  " 

Such  a  diet  may  be  made  very  palatable.  It 
may  not  be  well  relished  at  first  by  one  who  has 
made  meat  the  principal  element  of  his"  dietary. 
Much  meat -eating  spoils  one  for  less  highly  flavoured 
diet,  but  after  a  little  persistence  it  will  be  found 


THE    SEDENTARY    LIFE  459 

that  the  appetite  will  be  better  than  it  was  when 
so  much  meat  was  taken.  It  should  not  be  under- 
stood that  the  complete  disuse  of  meat  is  here 
advised.  It  may  be  taken  by  most  people  to 
advantage  once  a  day.  It  is  often  better  to  take 
a  small  amount  twice  a  day  rather  than  too  much 
at  one  meal. 

No  one  dietary  is  adapted  to  all  sedentary 
workers.  What  is  suited  to  one  may  not  be  to 
another,  for  people  of  every  temperament  and 
tendency  are  living  the  sedentary  life.  Something 
besides  the  mode  of  life  must  also  be  considered. 
The  fundamental  principle  is,  that  the  sedentary 
worker  should  largely  reduce  the  amount  of  albu 
minoid  or  nitrogenous  food,  of  which  meat  is  the 
chief  representative,  fats,  sugar,  coffee,  and  malt 
liquors.  It  is  rarely  best  to  wholly  eliminate  any 
of    them   from   the    diet    except    beer. 

A  second  important  principle  is,  that  the  amount 
of  aliment  taken  should  not  be  excessive.  Among 
the  cereals,  grains,  breads,  fruits,  vegetables,  green 
vegetables,  salads,  nuts,  fish,  shell-fish,  fowls, 
vegetable  oils,  butter,  milk,  cream,  eggs,  and  the 
combinations  that  can  be  made  from  them, 
there  is  certainly  material  for  the  making  of  a 
generous,  nutritious,  and  palatable  diet.  Out  of 
this    variety    each    one    should    select    what     his 


46o  HOW   TO    KEEP   WELL 

particular  taste   calls   for   and   what   his   own   ex- 
perience indicates. 

For  an  admirable  summary  of  this  question  of 
diet  for  the  sedentary  workers,  let  us  again  turn 
to  George  Cheyne:  "I  advise  all  gentlemen  of  a 
sedentary  life  to  use  as  much  Abstenance  as  possi- 
bly they  can  consistent  with  the  Preservation  of 
their  Strength  and  Freedom  of  their  Spirits,  which 
ought  to  be  done  as  soon  as  they  find  any  Heaviness, 
Inquietudes,  restless  Nights,  or  Aversion  to  Appli- 
cation ;  either  by  lessening  one-half  of  their  usual 
Quantity  of  animal  Food  and  strong  Liquors  until 
such  time  as  they  regain  their  wonted  Freedom; 
or  by  living  a  due  Time  on  vegetable  Diet." 

Adequate  and  proper  exercise  is  of  the  utmost 
importance  to  those  who  live  the  sedentairy  life. 
It  should  be  taken  every  day  in  approximately 
the  same  amount.  One  of  the  greatest  errors  is 
to  suppose  that  sufficient  exercise  can  be  taken 
once  or  twice  a  week.  A  long  bicycle  ride  on 
Saturday  afternoons,  or  a  "  century  run  "  on  Sunday, 
with  no  riding  during  the  week,  is  worse  than  no 
exercise.  The  person  who  is  not  exercising 
steadily  is  in  no  physical  condition  for  such  exces- 
sive efforts.  It  is  such  use  of  the  bicycle  which 
has  helped  to  bring  it  into  disrepute.  Women 
and    elderly    men    should    be    particularly    careful 


THE    SEDENTARY   LIFE  461 

regarding  such  intermittent  overexercise.  It  has 
been  justly  remarked  that  golf  and  the  bicycle 
before  middle  age  have  reduced  the  incomes  of 
medical  men,  and  after  middle  age  have  increased 
them.  This  is  because  the  exercise  is  too  severe 
or  is  overdone. 

It  is  an  error  to  suppose  that  heav}^  and  over- 
severe  exercise  is  beneficial  to  those  who  are  much 
confined  to  the  house.  No  sedentary  worker,  by 
any  exercise  he  can  take  outside  his  business  hours, 
can  keep  all  his  muscles  in  the  condition  of  those 
of  the  labourer  who  works  ten  hours  a  day.  He 
ought  not  to  expect  to  do  the  violent  work,  there- 
fore, that  the  labourer  does.  It  is  not  violent  exer- 
cise that  is  needed,  but  often-repeated  moderate 
exercise.  It  is  an  error,  also,  to  think  that  great 
muscular  development  is  desirable  in  a  brain- 
worker.  The  two  are  incompatible,  though  one 
often  sees  a  brilliant  brain  in  a  body  naturally 
.powerful.  Doctor  Holmes  has  cleverly  likened  great 
muscles  to  great  sponges  which  suck  up  and  make 
use  of  great  quantities  of  blood,  while  the  other 
organs  are  liable  to  suffer  for  the  need  of  their 
share.  Certain  it  is,  that  great  brain  power  does 
not  accompany,  as  a  rule,  enormously  developed 
muscles. 

Indoor    exercise    and    gymnasium     work    have 


462  HOW   TO    KEEP    WELL 

their  place,  and  an  important  one.  It  is  a  mistake, 
however,  to  rely  upon  such  exercise  alone.  For  a 
man  whose  business  is  in  the  house,  nothing  can 
take  the  place  of  outdoor  exercise.  For  most  inhabi- 
tants of  large  cities,  golf,  tennis,  and  horseback- 
riding  are  out  of  the  question.  Walking  and  bicy- 
cling are  all  that  is  available.  It  is  a  pity  that  the 
value  of  walking  as  an  exercise  is  not  better  appreci- 
ated. It  is  so  cheap,  and  always  available.  No 
special  costume  is  required;  there  is  no  groom 
nor  stable  man  to  annoy;  there  are  no  fees  to  be 
paid;  and  it  is  so  effective  in  quickening  the  circu- 
lation, working  off  superfluous  aliment,  and  keeping 
the  muscles  in  tone.  It  has  the  particular  advan- 
tage that  it  can  be  distributed  through  the  day, 
being  superior  in  this  regard  to  any  game  or  other 
form  of  exercise.  One  may  walk  a  little  farther 
to  take  the  car  to  business  in  the  morning.  He 
may  walk  a  little  farther  to  take  his  lunch,  or  take 
a  little  walk  after.  His  day  of  sedentary  work 
being  passed,  he  may  again  go  a  few  blocks  farther 
for  His  car,  and  straighten  out  the  curves  from 
his  legs  and  back.  At  night  there  is  still  more 
opportunity  for  this  exercise,  either  after  the 
evening  meal  or  just  before  bedtime.  This  exer- 
cise has  all  been  secured  through  the  day  with 
virtually  no  loss  of  time.     Of  all  the  forms  of  exer- 


THE    SEDENTARY   LIFE  463 

cise  available  for  the  average  sedentary  worker, 
walking  is  the  most  universally  useful,  and  should 
not  be  neglected. 

To  make  exercise  a  duty  rather  than  a  pleas- 
ure is  another  error  often  committed.  That  form 
of  exercise  that  is  most  to  the  taste  should  be 
selected.  It  should  not  be  taken  up  in  the  spirit  of 
the  martyr,  but  with  thankfulness  that  muscles 
have  been  given  to  us,  and  free  open  air  in  which 
to  exercise  them.  "Of  all  remedies  for  the 
nerves,  enjoyment  is  the  most  powerful,"  says 
Richter.  There  is  no  relief  for  tired  nerves  like 
moderate  rational  exercise  in  which  one  can  take 
pleasure. 

Bathing  should  be  a  factor  in  the  hygiene  of  those 
who  live  the  sedentary  life.  The  morning  bath 
should  be  considered  as  important  in  the  prepara- 
tion for  the  day  as  the  breakfast.  It  should  be  a 
cool  bath,  as  cool  or  as  cold  as  can  be  taken  with- 
out chill.  It  should  be  followed  by  a  good  "reac- 
tion." By  this  is  meant  that,  after  the  bath, 
followed  by  a  brisk  friction  of  the  surface  with  a 
towel,  there  should  be  a  warmth  and  glow  and 
feeling  of  invigoration.  The  temperature  of 
this  bath  cannot  be  stated,  for  it  must  vary  with 
different  individuals.  Some  cannot  take  it  to 
advantage  below  60°.     Others  can  learn  to  take 


464  HOW    TO    KEEP    WELL 

it  at  50°  and  even  40°.  In  the  summer  the  water 
may,  as  a  rule,  be  used  as  it  runs  from  the  faucet. 
In  New  York  the  temperature  is  about  70°. 
Elderly  people  and  delicate  women  and  children 
should  not  take  it  as  cool  as  this.  It  is  one  of  the 
greatest  errors  to  take  a  bath  so  cold  that  there  is 
an  excessive  shock  and  a  pinched  and  blue  con- 
dition afterward.  Such  bathing  will  render  a  person 
thin  in  flesh,  uncomfortable,  and  irritable.  Many 
a  child  has  been  injured  by  too  cold  bathing,  and 
many  an  adult  has  given  up  this  health-giving 
measure  because  he  used  the  water  too  cold  and 
remained  in  it  too  long.  Five  minutes  will  undo 
all  of  the  good  for  most  people.  A  minute  in  a 
cold  bath  should  be  the  limit.  It  is  then  a  power- 
ful stimulant  to  the  circulation  and  nervous 
system.  The  skin  takes  on  a  healthy  glow,  and  a 
feeling  of  well-being  replaces  the  disinclination  to 
begin  the  work  of  the  day  so  common  upon  waking 
in  the  morning.  It  should  be  understood  that  the 
cool  morning  bath  is  taken  as  much  for  this  reason 
as  for  cleanliness.  The  use  of  soap  is  advisable, 
for  fortunately  two  valuable  birds  may  be  hit  with 
one  stone.  There  are  very  few  individuals  of 
ordinary  health  who  cannot  take  to  advantage  a 
quick  morning  bath  ranging  somewhere  between 
60°   and    80°.      The    aged    and   feeble   should   not 


THE    SEDENTARY    LIFE  465 

attempt  it;  the  sedentary  worker  should  not 
omit    it. 

For  purposes  of  cleanUness  a  warm  bath  should 
be  occasionally  utilized,  and  is  best  taken  at  night. 
The  temperature  may  range  from  95°  to  105°, 
and  this  bath  may  be  continued  for  five  minutes. 
The  shower-bath  can  be  taken  to  great  advantage 
by  the  vigorous,  but  is  too  great  a  shock  for  many 
people,  even  those  who  can  safely  take  a  tub  bath. 
Its  introduction  into  modern  bathrooms  is  much 
to  be  commended,  but  its  use  should  not  be  abused. 
A  hot  foot-bath  at  night  is  often  an  effective  remedy 
for  insomnia.  It  is  also  an  aid  in  overcoming 
the  weariness  and  heaviness  of  head  felt  at  night 
by  brain- workers.  It  is  best  to  take  it  just  before 
retiring.  The  water  may  be  as  hot  as  can  be 
endured  (106°  to  112°),  and  may  be  continued  for 
ten  minutes.  This  hot  foot-bath  at  night  is  par- 
ticularly useful  for  elderly  people  who  sleep  poorly 
and  are  subject  to  cold  extremities. 

The  morning  tub  and  shower  bath  are  not  within 
the  reach  of  some,  but  there  are  very  few  to  whom 
the  sponge  bath  is  not  available.  The  cold  sponge 
is  almost  equal  to  the  tub.  It  may  be  utilized  in 
case  of  necessity,  and  should  be  chosen  by  elderly 
people  and  those  for  whom  the  tub  bath  is  too 
severe.     The  brisk  sponging  with  cold  water  and 


466  HOW    TO    KEEP    WELL 

vigorous  friction  of  the  skin  amply  repay  the  time 
and  trouble  it  costs.  A  secondary  but  by  no  means 
unimportant  result  obtained  from  all  bathing  is 
the  immunity  it  confers  against  the  liability  to 
take  cold.  Sponging  the  neck  and  shoulders  with 
cold  water  does  much  to  ward  off  colds  and  catarrh, 
but  general  bathing  does  more.  It  is  the  most 
efficient  of  preventive  measures  against  those 
visitations.  When  the  cold  bath  is  too  severe,  and 
is  followed  by  imperfect  reaction,  cold  sponging 
may  sometim.es  be  employed  while  the  individual 
stands  in  a  tub  of  water  at  about  ioo°.  The 
water  used  for  the  sponging  being  at  first  70°, 
may  be  slowly  reduced  until  a  temperature  of  50° 
can  be  tolerated.  This  is  an  excellent  way  to 
give  a  cool  bath  to  a  child.  It  can  be  so  tempered 
as  to  give  no  shock.  It  may  also  be  employed  by 
delicate  persons.  The  temperature  of  both  the 
tub  and  sponge  water  can  gradually  be  reduced 
until,  in  many  cases,  an  ordinary  cold  bath  can 
be  taken. 

A  final  element  of  importance  in  the  sedentary 
life  is  the  surroundings  in  which  the  labour  is  done. 
The  conditions  to  be  desired  are  five  in  number: 
proper  ventilation,  proper  heating,  freedom  from 
dust  and  dirt,  freedom  from  unnecessary  noise, 
and  adequate  light.     They  should  always  be  sought 


THE    SEDENTARY    LIFE  467 

for,  whether  their  full  attainment  be  possible  or 
not.  The  fact  is  of  course  recognized  that  there 
are  many  who  must  work  in  the  surroundings 
furnished  by  others  or  give  up  their  means  of  liveli- 
hood. There  are  others  who  might  do  something 
to  improve  their  surroundings  were  they  to  give 
thought  to  the  matter.  There  are  many  others 
who  have  the  matter  largely  in  their  own  hands. 
In  cities,  the  dust  and  noise  cannot  be  escaped, 
but  they  may  usually  be  reduced,  while  the  ventila- 
tion and  methods  of  heating  may  often  be  improved. 
It  is  employers  who  can  do  most  in  this  direction. 
It  is  a  simple  matter  of  business.  They  will  get 
vastly  more  work  out  of  employees  placed  in 
decent  surroundings  than  from  those  working 
in  unventilated,  improperly  heated,  and  dusty 
rooms  with  imperfect  light. 

When  the  surroundings  in  which  the  work  is 
done  are  reasonably  good,  the  sedentary  life  is  not 
necessarily  an  unhealthful  one.  The  one  who  must 
live  it,  by  adapting  his  methods  of  living  to  his 
methods  of  work,  by  keeping  out  of  ruts  and  taking 
some  pleasure  as  he  goes,  may  expect  to  attain  a 
good  old  age  with  as  much  assurance  as  does  the 
one  who  leads  a  more  active  life.  He  should  not 
repine  too  much  at  his  lot,  nor  should  he  regard 
himself  unfortunate  if  he  has  much  mental  work 


468  HOW   TO    KEEP   WELL 

to  do.  Mental  activity  is  not  unhealthful;  it  is 
eminently  advantageous.  Mental  workers  are 
high  -up  in  the  list  of  those  who  attain  long  life. 
The  mental  workers,  living  more  or  less  strictly 
the  sedentary  life,  are  among  those  who  are  doing 
most  to  advance  twentieth-century  civilization. 
The  position  is  one  to  be  thankful  for,  not  one  to 
regret. 


CHAPTER   XVIII 

Age    and    Its    Advancement 

An  old  age,  serene  and  bright,  is  a  consummation 
hoped  for  by  every  well-ordered  being.-  We  are 
assured  that  we  may  rightly  look  forward  to  three- 
score years  and  ten,  but  then  follows  the  sad 
assurance  that,  if  by  reason  of  strength  they  be 
fourscore  years,  yet  is  their  strength  labour  and 
sorrow.  This  is  not  uttered  as  a  malediction 
upon  old  age,  nor  even  as  a  statement  of  the 
inevitable,  but  as  a  comment  upon  an  often  ob- 
served fact.  AVhile  sorrows  and  troubles  are  no 
doubt  more  common  during  the  declining  years  of 
life  than  during  the  dawning  years,  we  may  do 
much  by  wise  living  to  prevent  bodily  afflictions 
and  the  sorrows  which  come  from  the  infirmities 
of  age. 

Mere  length  of  years  is  little  to  be  desired.     The}^ 

are  to  be  wished  for  only  if  they  bring  comfort  to 

oneself  and  usefulness  to   others.     The   expression 

is   sometimes   heard   that   long   life   is   not   to   be 

desired  if  it  must  be  purchased  by  asceticism  and 

abstinence  from  all  the  good  things  of  life.     There 

469 


470  HOW   TO    KEEP   WELL 

is  some  warrant  for  such  feelings.  A  life  barren  of 
all  pleasure  is  certainly  not  so  great  a  blessing 
that  one  would  greatly  desire  to  prolong  it.  But, 
fortunately,  asceticism  and  barrenness  of  life  are 
not  synonymous  with  right  living.  On  the  con- 
trary, right  living  is  the  most  certain  means  within 
our  own  control  of  obtaining  comfort  and  happiness. 
Do  not  make  the  error  of  thinking  that  those  who 
urge  methods  of  right  living  are  preaching  a  puri- 
tanical life.  The  old  puritanical  life  was  not  the 
best  kind  of  a  life  to  live,  though  it  was  infinitely 
better  than  the  life  it  protested  against.  It 
violated  some  of  the  fundamental  principles  of 
hygiene  and  right  living,  and  did  even  worse  in 
putting  a  ban  upon  cheerfulness  and  innocent 
pleasure.  It  was  too  somber,  and  took  a  dis- 
torted view  of  life.  Moderation  and  right  methods 
of  living  do  none  of  these  things.  They  tend 
strongly,  not  alone  to  prolong  life,  but  to  render 
it  comfortable  and  happy  throughout  its  whole 
course,  and  to  make  old  age  "as  a  lusty  winter, 
frosty  but  kindly."  Wrong  methods  of  living 
and  dissipation  do  not  always  seem  to  shorten 
life  materially,  but  sooner  or  later  they  almost 
infallibly  render  it  uncomfortable,  and  make  its 
last  years  miserable.  If  a  man  sow  to  the  whirl- 
wind, he  will  reap  destruction. 


AGE    AND    ITS   ADVANCEMENT       471 

vSome  excellent  things  regarding  the  diet  and 
general  management  of  those  in  advanced  years 
have  recently  been  written  by  Sir  Henry  Thompson, 
the  well-known  London  physician.  Always  inter- 
ested in  diet  and  hygiene,  he  first  wrote  upon  this 
particular  phase  of  the  subject  when  sixty-five 
years  old,  and  now,  a  still  vigorous  man  at  eighty- 
two,  he  writes  again.  This  work,  the  result  of 
years  of  trained  observation  confirmed  by  actual 
experience,  is  so  thoroughly  excellent  and  unique 
that  it  has  been  largely  drawn  upon  in  the  prepara- 
tion of  this  chapter.  Sir  Henry  holds  strongly 
that  diet  should  be  diminished  both  in  amount  and 
strength  in  advanced  life.  He  quotes  from  the 
writings  of  Luigi  Cornaro,  who  was  born  of  a  noble 
family  in  Venice  soon  after  the  middle  of  the 
fifteenth  century,  and  was  contemporary  for 
seventy  years  with  Titian.  He  wrote  his  first 
essay  on  the  subject  of  regimen  and  diet  for  the 
aged  when  he  was  eighty-three  years  old,  producing 
three  others  during  the  subsequent  twelve  years. 
His  object  was  to  show  that,  with  increasing  age 
and  diminishing  powers,  a  corresponding  decrease 
in  the  quantity  of  food  must  be  made  in  order  to 
preserve  health.  He  died  at  Padua,  "without 
any  agony,  sitting  in  an  elbow-chair,  being  above 
an  hundred  years  old." 


472 


HOW   TO    KEEP    WELL 


The   following  outline   of   diet   is   given  by.  Sir 
Henry:     "I  advise  as  a  typical  system  which  can 
be  varied  according  to  circumstances  and  personal 
idiosyncrasies  of  the  individual,  four  small  meals 
in   the    day.     Following   this    course,    the    animal 
food    supplied    for   breakfast    and    at    lunch    may 
include  eggs  or  fish  cooked  in  various  well-known 
ways.     At    lunch,    a    little    tender    meat    or    fowl 
may   be   taken,   unless   it   is   preferred   to   reserve 
them  for  dinner,  in  which  case  fish  and  a  farinaceous 
pudding   may     be    substituted.     This    last-named 
meal  should  generally  commence  with  a  little  good 
consomme;  often  substituting  a  vegetable    puree, 
varying  with  the  season,   and  made  with  a  light 
meat  stock  or  broth ;  or  a  good  fish  soup  as  a  change. 
Then  a  little  fowl  or  game  and  a  dish  of  vegetable, 
according  to  the  time  of  year.     Finally,  perhaps 
some  light  farinaceous  pudding,  with  or  without 
fruit,  should  close  the  meal,  which  is  to  be  a  light 
one  in  regard  to  quantity.     Lastly  supper:  a  very 
light  refreshment  may  be    advantageously    taken 
the  very  last  thing  before  entering  bed,  as  it  favours 
sleep.     All    animals    feed    before    resting    for    the 
night.     Few    meals    are    more    undesirable    for    a 
man  than  a  heavy  supper,  which  severely  taxes 
digestion.     But    elderly    men    especially    require 
some  easily  digested  food  to  support  them  during 


AGE   AND    ITS   iVDVANCEMENT      473 

the  long  fast  of  the  night.  It  is  well  known  that 
the  forces  of  the  body  are  at  their  minimuni  at 
4  or  5  A.  M.;  and  this  may  be  well  provided  for  by 
taking  about  five  or  six  ounces  of  consomme 
with  one  ounce  of  thin  toasted  bread  at  bedtime. 
Of  bread  eaten  at  meals,  it  may  be  said  that, 
whether  brown  or  white,  it  should  be  toasted;  the 
white,  as  containing  most  starch,  should  be  toasted 
thoroughly,  so  as  to  be  quite  brittle  "knd  show  the 
brown  colour  extending  through  its  interior;  the 
starch  is  thus  converted  into  glucose,  which  is 
soluble.  Quantity  during  the  meal,  from  three  to 
five  ounces  of  the  bread  before  toasting  it,  which, 
of  course,  diminishes  the  weight.  Fresh  butter  is 
the  most  generally  wholesome  of  all  fatty  matters 
which  come  to  the  table;  about  three  or  four 
ounces  may  be  taken  daily. 

"Very  weak  tea  is  general^  the  best  at  break- 
fast, with  a  good  proportion  of  milk;  and  with 
sugar  if  it  agrees.  This  is  not  to  be  taken  very  hot, 
and  about  five  minutes  after  the  conclusion  of  the 
meal.  At  lunch,  the  drink  may  include  a  breakfast 
cup  of  coffee  with  milk;  or  a  draught,  if  desired,  of 
pure  distilled  aerated  water,  either  to  be  taken 
after  the  meal." 

It  is  a  common  belief  that  light  alcoholic 
stimulation   is   more    suitable   to    advanced   vears 


474  HOW   TO    KEEP   WELL 

than  to  any  other  period  of  Hfe.  There  is,  no 
doubt,  some  truth  in  this.  The  reserve  powers 
are  far  less  abundant-  in  later  life  than  in  earlier 
years,  and  the  necessity  for  temporary  aid  in  tiding 
over  difficult  places  is  correspondingly  greater. 
Sir  Henry  Thompson  found  in  his  own  case  that 
the  daily  use  of  light  wine  at  about  seventy-five 
brought  joint  pains  and  sick  headaches,  which 
were  undoubtedly  gouty  in  their  nature.  Unless 
some  such  tendency  is  present,  experience  certainly 
shows  that  the  judicious  use  of  stimulants  may  add 
to  the  comfort  of  those  of  advanced  years.  On  the 
days  of  weakness  and  depression  which  come  so 
often  to  the  aged,  a  little  mild  stimulant  does  much 
to  render  life  more  comfortable.  There  are  times 
when  they  become  feeble  and  trembling,  when  it 
may  be  properly  given  several  times  a  day,  alwa3^s 
in  very  small  amounts.  The  moral  grounds  which 
render  unadvisable  the  giving  of  stimulants  to 
younger  people  do  not  apply  here.  The  doctor 
rarely,  if  ever,  sees  an  inclination  on  the  part  of 
the  aged  to  take  too  much.  The  opposite  tendency 
is  most  common. 

It  is  a  great  misfortune  for  the  aged  to  have  no 
occupation.  The  term  "  occupation "  should  be 
accepted  in  its  full  meaning — something  that  will 
occupy  tlie  mind  as  well  as  furnish  physical  exer- 


AGE   AND    ITS   ADVANCEMENT      475 

else  for  a  portion  of  each  day.  This  occupation 
must  vary  widely  with  different  individuals. 
The  man  of  seventy,  active  and  vigorous,  who 
is  anxious  to  go  to  his  business  each  day,  had 
better  be  permitted  to  do  so  without  too  much 
opposition  on  the  part  of  his  friends.  He  should 
certainly  shorten  his  hours  and  take  liberal  va- 
cations. He  should  lighten  his  responsibilities  and 
adjust  his  work  so  that  it  can  be  left  for  a  few  days  at 
any  time  without  causing  him  anxiety.  He  should 
never  forget  that  he  is  seventy  years  old,  no  matter 
how  young  he  may  feel.  On  the  day  of  this 
writing,  Russell  Sage  is  reported  by  the  papers  as 
having  been  in  his  office  yesterday  on  his  eighty- 
sixth  birthday,  engaged  in  his  usual  vocation  of 
making  short  loans  at  high  interest.  Many  men  at 
that  age  are  incapable  of  leaving  the  house.  They 
should,  however,  have  some  occupation  and  gentle 
exercise.  They  should  go  into  the  open  air 
daily  as  long  as  it  is  possible  to  do  so.  Being 
guided  by  his  taste  and  previous  habits  and  occu- 
pation in  life,  something  should  be  found  for  each 
to  do  which  will  occupy  a  part  of  the  time  each 
day.  This  is  a  more  difficult  task  for  a  man  con- 
fined to  the  house  than  for  a  woman.  Sewing, 
knitting,  and  partial  care  of  her  room,  and  many 
other  things  are  available  for  her.     The  stockings 


476  HOW   TO    KEEP   WELL 

she  knits  or  the  silk  quilt  she  makes  are  just  as 
creditable  to  her  as  are  the  dollars  which  Russell 
Sage  takes  in.  It  is  these  white-haired,  peaceful, 
though  often  feeble  old  people,  with  their  calming 
and  soothing  influence,  who  bring  most  certainly 
to  mind  the  words  of  Longfellow: 

"An  old  age  serene  and  bright, 
And  lovely  as  a  Lapland  night." 

It  is  these,  even  though  they  have  passed  far  beyond 
the  average  span  of  life,  that  the  doctor  finds  are 
watched  with  the  most  tender  solicitude,  for  the 
time  never  comes  when  the}^  can  be  spared. 

There  are  certain  kinds  of  advice  which  it  is 
unbecoming  for  younger  people  to  give  to  their 
elders.  There  are  one  or  two  points  of  importance, 
however,  upon  which  Sir  Henry  speaks  most 
wisely.  Being  an  octogenarian,  he  must  be 
looked  upon  as  one  who  speaks  with  authority. 
Another  extended  quotation  may  not,  therefore, 
be  inappropriate.  "I  cannot  close  my  subject," 
he  says,  "without  a  remark  or  two  respecting 
the  supreme  necessity  in  advancing  years  for  firm 
determination  to  resist  needless  self-excitement 
from  emotional  causes  of  all  kinds.  If  habits  of 
self-command  in  respect  to  diet  and  exciting 
drinks  have  been  steadily  cultivated,  it  is  probable 
that  a  due  control  of  temper  and  of  the  passions, 


AGE   AND    ITS   ADVANCEMENT       477 

and  the  avoidance  of  needless  sources  of  worry  or 
anxiety,  should  come  to  be  regarded,  not  only  as 
one  of  the  main  objects  of  life  at  this  period,  but 
also  as  an  attainable  one  to  a  great  extent — the 
first  discipline  having  been  useful  in  training  the 
will  to  exercise  restraint  and  self-denial.  Each 
period  of  man's  personal  history  brings  its  own 
appropriate  duties  and  employments.  By  no 
means  the  least  of  those  which  accompany  old 
age  is  a  satisfactory  sense  of  the  absence  of  desire 
for  pursuits,  which  there  is  now  little  inducement, 
or  perhaps  ability,  to  cultivate. 

"Again,  men's  opinions  are  apt  to  become  more 
or  less  fixed,  as  experience  increases  and  habits  of 
thought  are  formed.  It  is  undesirable  to  assert 
these  too  strongly  in  the  form  of  advice,  much 
less  to  endeavour  to  impose  them  upon  our  chil- 
dren, whose  ways  are,  naturally,  not  as  our  ways. 
Indeed,  sound  and  wise  as  our  advice  to  young 
people  may  be,  great  allowance  must  be  made  for 
the  fact  that  they  must,  will,  and  even  ought, 
within  certain  limits,  to  deal  in  their  own  way 
with  the  incidents  they  encounter  in  the  early 
stages  of  life's  journey,  and  learn  by  their  own 
experience — as  we  ourselves  did — paying,  however, 
rather  dearly  for  their  lessons,  perhaps." 

It  is  a  wise  thing  for  some  men  to  retire  early 


478  HOW   TO    KEEP   WELL 

from  business  or  professional  life,  and  very  unwise 
for  others.  It  depends  upon  the  character  of  the 
man.  Some  men  stagnate.  They  become  rest- 
less, irritable,  and  unhappy,  and  actually  degen- 
erate. This  is  apt  to  be  true  of  "self-made"  men. 
A  man  who  took  up  his  business  in  early  manhood 
or  acttial  boyhood,  and  has  worked  up  to  fortune 
and  success,  toiling  in  the  one  channel  in  season 
and  out  of  season,  year  after  year,  giving  no  atten- 
tion to  other  subjects,  had  better  not  leave  that 
channel  entirely,  nor  wander  too  far  from  it.  In 
other  words,  he  should  not  retire  wholly  until 
waning  strength  forces  the  issue.  The  lawyer  or 
merchant  who  has  studied,  thought,  and  talked 
nothing  but  law  or  business,  cannot  safely  retire 
when  he  has  acquired  a  competence.  He  has  no 
resources  to  fall  back  upon.  He  will  become 
weary  of  existence,  and  die  of  dry  rot.  Had 
Russell  Sage  been  obliged  to  retire  at  the  age  limit 
of  the  Army  and  Navy,  he  would  probably  have 
been  in  his  grave  years  ago.  A  Carnegie,  however, 
can  "retire"  with  complete  safety,  as  could  a 
Weir  Mitchell,  an  Oliver  Wendell  Holmes,  and 
hundreds  of  other  broad-gauge  men.  It  is  con- 
ceivable that  the  present  President  of  the  United 
States  may  retire  from  public  life  upon  completing 
his  term  of  office,  but  it  is  not  conceivable  that  he 


AGE   AND    ITS   ADVANCEMENT       479 

will  stagnate  or  shorten  his  life  thereby.  He  is 
what  Holmes  calls  a  three-story  man,  and  gets 
light  through  more  than  one  set  of  windows.  If 
driven  off  the  lower  floor,  he  has  abundance  of 
room  on  the  upper  ones.  One-story  men,  how- 
ever, must  retire  to  the  garret,  where  they  will 
waste  away  for  the  want  of  light  and  air.  In  this 
age  of  specialism  it  is  a  w4se  parent  who  endeavours 
to  train  his  child  to  be  an  expert  in  some  kind 
of  work,  but  he  should  also  see  to  it  that  in  the 
building  of  character  he  has  something  more  than 
a  garret  above  the  first  floor.  It  is  a  comforting 
thing  to  have  some  mental  resource  to  fall  back 
upon  when  one  wishes  to  retire  from  active  labour, 
whether  it  be  for  a  vacation  in  middle  life,  or 
permanently  in  later  life. 

Quite  different  from  retiring  from  business  or 
professional  life  is  the  question  of  resigning  cer- 
tain official  positions  as  age  advances.  The 
business  man  and  man  of  affairs  holds  numerous 
positions  upon  boards  and  directories  or  official 
positions  in  clubs  or  societies.  The  lawyer  is  apt 
to  hold  offices  of  semi-public  nature.  The  phy- 
sician holds  positions  in  colleges  and  hospitals. 
Many  such  positions,  while  not  lucrative,  involve 
more  or  less  labour  and  responsibility.  They 
serve  as  useful  aids  to  men  in  earlier  life  in  getting 


48o  HOW   TO    KEEP   WELL 

on  in  the  world.  In  later  life  they  have  no  such 
value,  and  yet  they  are  often  persistently  held  by 
men  in  advanced  years.  Some  temperaments 
show  a  strong  aversion  to  doing  anything  that 
may  seem  an  acknowledgment  that  they  are 
getting  old.  They  find  it  almost  impossible 
to  give  way  to  those  who  are  younger,  and  are 
jealous  of  those  who  may  succeed  them.  When 
they  reach  a  certain  age  they  lose  the  ability  to 
comprehend  when  they  become  ineffective.  A 
prominent  surgeon  recently  said  that  when  he 
became  sixty-four  he  intended  to  resign  his  hospital 
and  other  similar  positions,  for  he  would  never 
know  enough  to  do  so  afterward.  There  is  noth- 
ing more  sad  than  to  see  a  man  impair  a  fine 
record  or  great  reputation  through  not  knowing 
when  to  stop.  This,  however,  is  but  one  reason 
for  resigning  extraneous  and  less  important  posi- 
tions. As  a  man  approaches  later  life,  he  ought  to 
gradually  lighten  his  burdens  as  far  as  he  can. 
These  positions,  being  of  less  vital  importance, 
should  be  the  first  to  be  thrown  off.  He  has 
little  to  gain  from  many  of  them,  while  they  may 
be  of  considerable  value  to  younger  men.  After 
he  has  held  them,  therefore,  for  years,  and  profited 
by  them,  it  is  only  fair  to  give  way  to  others.  A 
source  of  unhappiness  which'  one  sometimes  sees 


AGE   AND    ITS   ADVANCEMENT       481 

in  the  aged  is  inability  to  thus  give  way  to  others 
and  permit  those  who  are  younger  to  do  things 
in  their  own  way  and  according  to  their  own  ideas. 

Men  are  not  alone  in  this,  for  one  often  sees 
elderly  women  in  churches  and  social  organizations 
holding  offices  and  doing  work  which  younger 
women  could  do  better,  and  would  do  if  the  oppor- 
tunity were  afforded.  Every  generation  has  its 
workers  and  individuals  qualified  to  perform 
special  tasks.  Some  one  will  appear  to  do  the 
necesS'ary  work  of  the  world,  for  there  is  no  evi- 
dence to  lead  us  to  think  that  the  rising  generation 
will  be  less  competent  or  less  willing  to  work  than 
is  our  own. 

At  no  period  in  life  is  the  golden  mean  more  desir- 
able than  in  old  age.  Idleness  is  conducive 
neither  to  happiness,  health,  nor  longevity.  It  is 
to  be  shunned.  Activity  is  healthful.  "It  is 
better  to  wear  out  than  to  rust  out."  But  upon 
the  other  extreme,  sudden  and  excessive  exertion 
is  to  be  guarded  against.  In  old  age  the  reserve 
power  is  slight,  and  certain  organs  are  easily  over- 
taxed. One  who  might  go  on  for  years  doing 
ordinary  work  may  give  out  suddenly  under 
some  unusual  and  excessive  strain.  Hence,  un- 
usual and  excessive  labour  or  gymnastic  exercises 
should  be  avoided.     Bicycling  is  often  the  cause 


482  HOW    TO    KEEP    WELL 

of  injury  to  those  who  have  passed  middle  life, 
because  of  the  temptation  to  overdo,  and  to  put 
sudden  and  excessive  strains  upon  the  heart, 
arteries,  and  lungs.  Golf  is  also  capable  of  doing 
similar  injury.  Among  the  exercises  especially 
adapted  to  later  life  are  walking  and  gardening. 
The  latter,  when  it  is  available,  is  perhaps  the 
most  excellent  form  of  physical  exercise  for  an 
elderly  man.  The  purchase  of  a  place  in  the 
country,  or  of  a  small  farm,  is  an  admirable  scheme 
for  a  well-to-do  city  worker  of  middle  age.  It 
will  take  his  mind  from  the  cares  of  business 
during  the  winter  when  he  is  laying  his  plans  for 
the  coming  season,  and  will  give  him  out-of-door 
exercise  of  the  most  healthful  kind  during  the 
summer.  Most  men  become  deeply  interested 
in  such  a  place  and  the  work  connected  with  it.  It 
furnishes  an  incentive  to  activity  without  over- 
stimulation and  excitement.  And  the  expense 
need  not  be  large.  In  no  other  way  can  an  elderly 
man  so  renew  his  youth  and  prolong  his  days. 

The  management  of  the  aged  in  illness  may 
properly  receive  a  word  of  attention.  The  secret 
of  successful  management  lies  in  maintaining  the 
strength  and  conserving  the  vitality,  for  the  hold 
on  life  is  less  firm  than  during  the  period  of  vigour 
of  earlier  years.     This  is  accomplished  by  enforcing 


AGE   AND    ITS   ADVANCEMENT       483 

quiet  and  by  systematic  feeding  and  stimulation. 
Concentrated  nourishment  should  be  given  at 
short  intervals.  Beef  juice,  milk,  broths,  and  eggs 
may  be  given  every  two  or  three  hours.  This  is 
not  a  contradiction  to  advice  regarding  a  light 
diet  which  was  given  in  the  early  part  of  this 
chapter.  The  appetite  is  apt  to  be  so  small  that 
sufficient  is  not  taken  to  maintain  the  strength 
if  the  interval  is  too  long.  While  avoiding  the 
extreme  of  overloading  the  digestion  or  giving 
more  than  would  be  taken  in  health,  this  systematic 
feeding  is  very  important. 

The  advice  offered  in  this  chapter  may,  perhaps, 
be  enforced  as  well  as  summarized  by  referring 
again  to  our  old  friend,  George  Cheyne,  who  says, 
"Every  wise  Man  after  Fifty  ought  to  begin  to 
lessen  the  Quantity  of  his  Aliment ;  and  if  he  would 
continue  free  of  Great  and  Dangerous  Distempers, 
and  preserve  his.  Senses  and  Faculties  clear  to  the 
last,  he  ought  every  seven  Years  to  go  on  abating 
gradually  and  sensibly,  and  at  last  descend  out  of 
Life  as  he  ascended  into  it,  even  into  the  Child's 
Diet." 


CHAPTER   XIX 

Modern    Surgery 

"Surgery  has  virtually  reached  its  limits," 
said  Erichsen,  the  great  English  surgeon,  barely 
twenty-five  years  ago.  Such  a  statement  lends 
force  to  the  belief  that  the  vocation  of  the  modern 
prophet  is  one  of  great  precariousness.  At  the 
time  this  statement  was  made,  there  was  every 
evidence  that  it  was  well  founded.  The  surgeon 
at  that  time  was  a  master  of  anatomy  and  an 
expert  in  surgical  technique.  Under  conditions 
as  they  then  existed  there  was  really  but  little 
prospect  of  material  advancement. 

But  the  conditions  changed,  and  following  hard 
upon  that  change  came  an  advancement  so  great 
as  to  amount  almost  to  revolution.  It  is  not  an 
exaggeration  to  say  that  were  Sir  Astley  Cooper  or 
Valentine  Mott  to  return  to-day  to  the  scenes  of 
their  labours  and  triumphs  they  would  not  be 
permitted  to  operate  in  any  hospital  in  the  civilized 
world.     Sir  Astley  hesitated  to  operate  on  George 

IV.  for  a  wen,  as  he  feared  erysipelas,  a  serious 

484 


MODERN    SURGERY  '   485 

matter  for  a  surgeon  in  so  great  a  patient.  At  that 
time  pus  formation  was  expected  after  almost 
every  operation,  and  the  surgeon  was  happy  if  he 
escaped  erysipelas  or  other  forms  of  septic  infection. 
If  these  things  occur  now  the  surgeon  calls  a  sudden 
halt  in  his  operating,  and  scrutinizes  every  detail 
not  only  of  his  own  work,  but  that  of  his  assistants 
and  nurses.  Formerly  the  surgeon  was  perfectly 
satisfied  if  the  pus,  which  came  as  a  matter  of 
course,  was  smooth  and  light  coloured.  This  he 
called  "laudable  pus."  He  began  to  worry  only 
when  the  discharge  became  "ichorous"  or  "sanious." 
The  causes  for  the  radical  changes  in  surgical 
procedures  and  in  the  results  attained  are  many, 
but  two  stand  out  so  preeminently  as  to  over- 
shadow all  the  rest — anesthesia  and  antisepsis. 
The  discovery  of  anesthesia  was  one  of  the  great 
events,  not  only  of  surgical  history,  but  of  all 
history.  Its  results  are  not  limited  to  the  saving 
of  pain,  as  is  the  popular  belief.  It  is  one  of  the 
great  life-saving  measures  of  modern  times.  Before 
anesthesia,  the  most  rapid  operator  was  the  most 
successful  surgeon;  now  it  is  the  careful  and  pains- 
taking operator.  Then  everything  was  sacrificed 
to  rapidity;  now  rapidity  is  of  minor  importance. 
Painstaking  care  in  every  detail  is  the  first  essential. 
Few  of  the  wonderful  operations  upon  the- abdomen 


486  HOW   TO    KEEP   WELL 

and  the  delicate  organs  of  the  body  could  be  per- 
formed with  success  upon  a  suffering  and  struggling 
patient.  The  very  muscular  relaxation  resulting 
from  anesthesia  is  necessary  to  the  success  of 
many  delicate  and  formidable  operations.  Thou- 
sands of  operations  are  performed  for  the  relief  of 
suffering  or  the  cure  of  disease  which  without  an 
anesthetic  would  never  be  attempted. 

Few  at  the  present  day  realize  the  changes  in 
surgical  practice  that  have  been  wrought  by 
anesthesia.  Before  its  introduction  into  the 
Massachusetts  General  Hospital,  but  thirty-seven 
operations  were  performed  per  year.  In  the 
first  five  years  after  that  event,  operations  aver- 
aged more  than  loo  in  number.  In  1900,  in  the  same 
hospital,  more  than  3,700  operations  were  per- 
formed. It  is  not  uncommon  for  a  surgeon  to 
perform  300  or  400  operations  a  year,  and  many 
prominent  surgeons  do  more  than  this.  This 
means  the  prolonging  of  many  lives.  Ovarian 
tumours,  for  example,  commonly  occur  at  or  before 
middle  life,  and  are  fatal  if  not  removed.  Ovari- 
otomy is  an  operation,  however,  which  surgeons 
would  hesitate  to  perform  without  an  anesthetic, 
and  few  patients  would  submit  to  it.  When 
Sir  Spencer  Wells  reported  his  first  series  of 
1 ,000  operations  for  ovariotomy,  it  was  estimated 


MODERN    SURGERY  487 

that  he  had  added  20,000  years  to  the  sum  of 
human  Hfe. 

As  skill  is  largely  the  result  of  experience,  this 
large  yearly  experience  adds  immensely  to  the 
skill  of  the  operator,  and  consequently  improves 
his  results.  It  is  undoubtedly  true  that  never 
in  the  history  of  the  world  has  the  average  tech- 
nical skill  of  surgeons  been  so  great  as  it  is  to-day. 
There  are  scores  of  surgeons  to-day  of  not  wide 
popular  reputation  who  have  actually  greater 
technical  skill  than  had  some  of  the  great  celebri- 
ties of  the  past.  In  the  older  times  a  surgical 
operation  was  a  remarkable  event  in  a  medical 
college,  and  the  students  gave  up  everything  else 
to  see  it.     Now  they  are  an  everyday  occurrence. 

The  question  of  the  discovery  of  the  anesthetic 
power  of  sulphuric  ether  has  been  largely  debated. 
The  honour  was  claimed  by  four  men,  Morton  of 
Massachusetts,  Long  of  Georgia,  Wells  of  Connecti- 
cut, and  Jackson  of  Massachusetts.  Each  of 
these  men  have  had  their  followers,  but  by  quite 
universal  consent  the  credit  is  awarded  to  Morton. 
Other  discoveries  visited  America  before  Columbus, 
and  other  men  knew  of  the  anesthetic  power 
of  ether  before  Morton,  but  still  the  honour  of 
discovery  is  no  more  justly  given  to  the  one  than 
to    the    other.     "While    Long    waited    and    Wells 


488  HOW    TO    KEEP    WELL   * 

turned  back  and  Jackson  was  thinking,"  says 
Sir  John  Paget,  "Morton,  the  practical  man, 
went  to  work  and  worked  resolutely. ' '  The  discovery 
was  made  by  him  with  but  little  knowledge  of 
what  the  others  had  done,  and  the  fortunate 
circumstance  of  residence  in  a  large  city  enabled 
him  to  bring  his  discovery  very  quickly  to  the 
knowledge  of  the  world.  Whatever  the  claims 
of  others  may  be,  practically,  the  use  of  ether 
dates  from  October  i6,  1846.  In  the  Massachusetts 
General  Hospital,  in  Boston,  on  that  day,  William 
T.  G.  Morton  first  used  sulphuric  ether  as  an 
anesthetic  for  a  serious  surgical  operation. 

The  report  of  that  event  by  an  eye  witness  is 
most  interesting.  The  test  was  to  be  made  in  the 
amphitheatre  of  the  hospital,  upon  a  patient  of 
Doctor  J.  C.  Warren.  Much  skepticism  or  actual 
unbelief  in  the  discovery  was  felt,  and  those  as- 
sembled looked  only  for  failure.  Doctor  Morton 
was  late,  and  when  Doctor  Warren  remarked,  "As 
Doctor  Morton  has  not  arrived,  I  presume  he  is 
otherwise  engaged,"  there  was  a  general  smile 
of  derision.  Doctor  Morton  soon  entered,  however, 
and  at  once  began  his  work.  "Instructing  his 
patient  to  breathe  deep  and  long,  and  to  have 
confidence  in  him,  he  skilfully  piloted  him  into 
that  profound  state   of  ether  narcotism  we  now 


MODERN   SURGERY  489 

know  so  well.  It  was  then  that  he  said,  'Your 
patient  is  ready.'  The  first  incision  was  made 
and  there  was  no  sign  of  suffering.  A  pin  could 
have  been  heard  to  fall,  so  intense  was  the  silence. 
Doctor  Warren  completed  the  operation  and 
inserted  the  stitches.  Still  no  sign  of  pain.  The 
patient  slumbered  as  peacefully  as  a  child  in 
happy  dreams.  Doctor  Warren  turned  slowly 
from  that  recumbent  figure.  Looking  up  at  those 
eager  faces,  he  said  quietly,  'Gentlemen,  this  is 
no  humbug.'  " 

From  that  day  the  use  of  ether  rapidly  spread 
through  the  civilized  world,  and  has  steadily 
gained  in  favour.  Although  other  anesthetics 
have  been  discovered  and  have  been  applied  for 
special  cases,  the  use  of  ether  is  still  universal. 
As  an  efficient  and  safe  anesthetic  no  rival  has 
been  found  to  supplant  it. 

The  surgeon  of  sixty  years  ago  would  find  much 
that  is  new  in  the  modern  hospital,  and  would 
be  unable  to  account  for  the  absence  of  many 
things  with  which  he  was  familiar.  The  heavily 
padded  doors  of  the  operating  room,  which  allowed 
no  shriek  of  suffering  to  pass  to  the  hospital  beyond ; 
the  hooks  in  the  floors  and  the  ropes  with  which 
to  bind  down  the  struggling  victim;  the  stalwart 
assistants   to   add   their   strength   to   that    of   the 


490  HOW   TO    KEEP   WELL 

ropes — all  these  things  have  disappeared  forever. 
But  the  name  of  the  man  who  wrought  these 
changes  is  known  to  but  one  in  a  thousand.  It 
is  a  strange  commentary  on  the  fickleness  of  fame. 
In  the  year  following  Morton's  demonstration 
in  Boston,  Sir  James  Y.  Simpson,  the  great  Edin- 
burgh physician,  demonstrated  the  anesthetic 
power  of  chloroform.  It  is  true  that  chloroform 
had  been  discovered  in  this  country  sixteen  years 
before,  and  had,  perhaps,  been  used  as  an  anes- 
thetic, but  to  Simpson  belongs  all  the  credit  for 
the  real  discovery  of  its  anesthetic  powers. 
Chloroform  is  a  pleasanter  anesthetic  than  ether. 
It  takes  effect  and  passes  away  more  quickly,  and 
is  less  liable  to  cause  nausea.  It  is,  however, 
variable  in  its  action,  and  not  as  safe  as  ether  for 
ordinary  surgical  cases.  Except  in  certain  selected 
cases,  it  is  not  largely  used  by  surgeons  in  this 
country.  In  obstetrical  cases  there  are  special 
conditions  present  which  render  safe  the  use  of 
chloroform.  It  is  one  of  the  greatest  blessings 
given  to  suffering  womanhood.  When  it  can  be 
received  from  the  hands  of  a  competent  and  careful 
physician,  it  need  not  be  refused  through  fear. 
Queen  Victoria  was  one  of  the  first  women  to  take 
chloroform  during  confinement,  and  her  action 
did  much  to  hasten  its  general  adoption  in  such 


MODERN    SURGERY  491 

cases.  She  did  this  at  the  request  of  Sir  James  Y. 
Simpson,  who  was  her  physician,  one  object  in  her 
mind  being  to  popularize  its  use.  She  was  also 
the  first  patient  upon  whom  Lord  Lister  used  an 
india  rubber  drainage  tube.  This  was  done  in 
opening  a  small  abscess  of  the  axilla.  It  is  a  matter 
of  passing  interest  that  the  term  "anesthetic"  was 
devised  by  Doctor  Oliver  Wendell  Holmes,  for 
many  years  the  professor  of  anatomy  in  the 
Harvard  Medical  School. 

The  term  "antisepsis"  is  commonly  employed  to 
designate  the  system  of  cleanliness  designed  to 
prevent  the  entrance  of  bacteria  into  wounds, 
abrasions,  and  sores.  Lord  Joseph  Lister  is  the 
father  of  antiseptic  surgery,  and  is  still  living. 
No  definite  date  can  be  given,  either  for  its  dis- 
covery or  announcement  to  the  world,  though 
the  summer  of  1876  is  commonly  considered  the 
starting  point.  At  that  time,  Lord  Lister,  then 
plain  Doctor  Lister,  demonstrated  certain  methods 
of  procedure  before  the  International  Medical 
Congress  in  session  in  Philadelphia.  His  ideas  were 
quickly  grasped  by  a  few  surgeons,  particularly  in 
America,  and  the  system  rapidly  and  steadily  grew 
and  expanded.  So  overwhelming  was  the  evi- 
dence of  its  efficiency  that  it  has  been  years  since 
any   surgeon    dreamed    of   intentionally    violating 


492  HOW   TO    KEEP   WELL 

its  fundamental  principles.  The  methods  of 
Listerism,  as  the  system  was  known  in  its  earlier 
years,  have  been  radically  changed,  and  to  the 
superficial  observer  there  is  little  in  common 
between  it  and  modern  asepsis.  The  fundamental 
underlying  principles,  however,  are  the  same. 
Change  has  come  as  steadily  increasing  knowledge 
has  shown  better  methods  of  securing  the  ends 
sought. 

At  first  it  was  supposed  that  the  bacteria  of 
wound  infections  were  derived  chiefly  from  the 
air,  and  cumberous  sprays  were  used  over  the  site 
of  operation.  It  was  soon  learned,  however,  that 
bacteria  adhered  to  everything — the  hands,  instru- 
ments, sponges,  and  dressings.  Nothing  is  free 
from  them.  Then  came  the  prolonged  washing 
of  the  hands  with  soap  and  antiseptics,  and  later 
the  use  of  rubber  gloves  which  have  no  crevices 
and  creases  for  the  lodging  of  bacteria.  Instru- 
ments and  dressings  were  sterilized  by  heat  or 
antiseptics.  The  details  have  constantly  changed, 
but  the  end  sought  has  always  been  the  same — 
the  destruction  or  exclusion  of  germs.  To-day 
greater  attention  is  given  to  the  exclusion  of 
germs  than  formerly,  and  to  this  system  is  more 
properly  applied  the  term  "asepsis."  It  is  better 
than  antisepsis,  which  gives  more  thought  to  the 


MODERN    SURGERY  493 

destruction  of  germs,  because  prevention  is  always 
better  than  cure.  Antisepsis  and  asepsis,  how- 
ever, are  closely  combined,  and  are  but  part  of 
the  same  system  which  seeks  to  keep  wounds  and 
sores  free  from  living  germs. 

Surgery  has  lost  much  of  its  brilliancy  and  glitter 
since  the  days  when  a  spectator  stood  with  open 
watch  and  the  operation  was  done  w^ith  a  dash 
and  flourish.  Showy  operations  like  amputations 
are  now  comparatively  less  common  than  they 
formerly  were.  An  operation  to-day  is  a  careful, 
painstaking  procedure,  hedged  about  with  a 
multitude  of  commonplace  and  wearying  details. 
Much  of  the  dash  and  brilliancy  is  gone,  for  the 
operation  is  not  finished  until  every  portion  of  the 
offending  growth  has  been  dissected  away,  and  the 
minute  outlying  glands  have  been  searched  for 
and  removed  one  by  one,  and  every  bleeding 
point  has  been  stopped.  Important  antiseptic 
details  are  carried  out  at  every  step,  an  error  in 
any  one  of  which  will  endanger  the  full  success  of 
the  operation.  These  details  seem  to  the  onlooker 
intricate  in  the  extreme.  The  reason  for  every 
one,  however,  is  so  obvious,  and  the  surgeon  is  so 
trained  to  neglect  none  of  them,  that  he  forgets 
that  they  are  intricate.  The  young  medical  man 
is,   in  fact,  so   trained  to   these  methods,  that   he 


494  HOW    TO    KEEP    WELL 

forgets  that  there  is  any  other  way  to  perform 
an  operation,  and  they  become  as  a  second  nature. 
A  very  few  statistics  showing  the  results  of  these 
methods  will  suffice  to  demonstrate  that  all  this 
trouble  is  not  taken  in  vain.  Compound  fracture, 
in  which  an  end  of  the  broken  bone  protrudes 
through  the  skin,  was  formerly  one  of  the  most 
dreaded  of  accidents.  The  old  mortality  was  about 
60  per  cent.,  and  amputation  was  often  necessary 
among  those  who  survived.  The  mortality  now 
is  a  trifle  more  than  3  per  cent.,  and  amputation 
is  rare.  Compound  fractures  are  still,  however, 
accidents  of  serious  import.  The  old  mortality 
of  major  amputations  was  from  50  to  65  per 
cent.;  it  is  now  between  10  and  20  per  cent.  The 
old  mortality  of  ovariotomy  was  also  about  60 
per  cent.  In  1862  a  prominent  surgeon  said  that 
the  man  who  performed  that  operation  should 
be  indicted  for  manslaughter.  Now  a  mortality 
of  3  per  cent,  is  large  for  cases  that  are  not  cancer- 
ous. Many  surgeons  report  series  after  series  of 
100  cases  each  without  a  death.  The  abdomen, 
a  region  formerly  much  feared  by  the  surgeon,  is 
now  opened  with  the  utmost  safety.  He  seeks 
tumours  here,  as  well  as  in  the  chest  and  skull,  with 
little  fear.  In  fact,  the  surgery  of  tumours,  which 
includes  not  alone  their  removal,  but  a  knowledge 


MODERN    SURGERY  495 

of  their  nature  and  growth,  has  made  particular 
progress.  They  are  removed  even  though  adherent 
to  veins  and  arteries  and  important  organs.  In 
the  neck,  where  the  muscles,  nerves,  veins,  and 
arteries  are  packed  together  more  closely  than  in 
any  other  region  of  the  body,  the  surgeon  dissects 
out  tumours  in  a  way  that  is  truly  marvelous. 
He  ties  large  and  important  arteries  when  they 
obstruct  his  path  or  when  they  feed  growths  whose 
removal  is  beyond  his  skill  and  daring.  He  removes 
whole  sections  of  the  bowel  and  unites  their  cut 
ends.  He  frequently  removes  a  kidney,  in  olden 
times  one  of  the  most  formidable  operations  of 
surgery,  or  cuts  down  and  takes  out  a  stone  from 
its  interior.  He  takes  away  impacted  liver  stones 
which  would  otherwise  cause  death — and  takes 
bullets  out  of  the  brain  and  drains  brain  abscesses. 
These  are  among  the  common  operations  of  modern 
surgery,  and  are  not  in  the  catalogue  of  rarer  opera- 
tions, like  removal  of  the  stomach  and  stitching  of 
wounds  in  the  heart. 

The  rate  of  mortality  has  been  lowered  in  almost 
every  surgical  operation.  A  New  York  surgeon 
has  recently  reported  639  operations  for  hernia 
with  one  death.  Many  of  these  patients  w^ere 
young  children,  who  are  supposed  to  bear  opera- 
tions badly.    In  1876,  Doctor  Gross  referred  to  the 


496  HOW   TO    KEEP   WELL 

unusual  fact  that  a  certain  surgeon  had  performed 
seven  operations  for  goiter  with  but  two  deaths. 
In  1898,  Kocker,  of  Berne,  reported  the  removal 
of  556  goiters  of  non-cancerous  nature  with  but 
one  death.  Macewen,  of  Glasgow,  has  recently 
reported  1,800  operations  for  deformed  limbs  on 
704  patients,  in  which  the  bone  was  sawed  or 
chiseled,  with  five  deaths  following.  In  three  of 
these,  pneumonia,  scarlet  fever,  and  diphtheria 
were  contributing  causes.  Surgery  for  the  cor- 
rection of  deformities  has  of  late  years  been  par- 
ticularly satisfactory,  and  is  virtually  free  from 
danger.  In  this  branch  of  the  art,  American 
surgeons  have  been  very  successful.  Some  of  the 
remarkable  operations  of  recent  years  have  been 
those  performed  upon  the  head,  and  have  been 
made  possible  by  a  knowledge  of  "brain  locali- 
zation," which  has  become  a  science  in  itself.  It 
has  made  ridiculous  the  old  phrenology,  the  science 
of  bumps  on  the  exterior  of  the  skull,  and  has  not 
left  it  a  solitary  thread  to  hang  by. 

Abdominal  surgery  in  its  various  forms  is  almost 
a  new  science.  Peritonitis  was  a  nightmare  to 
the  older  surgeons,  and  well  it  might  be.  The 
peritoneum  is  the  membrane  which  lines  the  abdomi- 
nal wall,  from  which  it  is  reflected  onto  the  intes- 
tines and  various  organs.     It  covers  nearly  every 


MODERN    SURGERY  497 

portion  of  these  structures,  and  is  therefore  enor- 
mous in  extent.  It  is  smooth  and  shiny,  and  is 
designed  to  allow  the  various  structures  of  the 
abdomen  to  play  upon  each  other  without  friction. 
Inflammation  roughens  this  smooth  surface  and 
irritates  the  nerves.  The  pain  engendered  by 
peritonitis  is  agony  which  must  be  felt  to  be 
comprehended.  There  are  two  other  membranes 
in  the  body  of  similar  type,  known  as  serous 
membranes.  These  are  the  pleura  in  the  chest, 
and  the  meninges  in  the  skull.  Pleurisy  and 
meningitis  are  characterized  by  agonizing  pain,  as 
is  peritonitis.  These  membranes  are  all  very 
sensitive,  particularly  to  bacterial  infection.  In- 
flammation once  started  from  a  local  centre  tends 
to  spread  rapidly  and  involve  wide  areas.  No 
wonder,  therefore,  that  the  old  surgeons  feared  the 
abdomen,  the  chest,  and  the  head.  One  of  the 
greatest  triumphs  of  the  modern  surgeon  is  his 
ability  to  handle  these  membranes  with  virtually 
no  danger  of  starting  up  an  inflammation.  In 
case  of  injury  to  the  abdomen,  as  a  bullet  wound, 
he  does  not  sit  idly  by,  waiting  for  the  peri- 
tonitis, and  relieving  the  pain  with  opium,  until 
the  patient  succumbs.  He  opens  the  abdomen, 
stitches  up  the  wounds  in  the  intestine,  and  washes 
out    the    intestinal    contents    which    have    leaked 


498  HOW   TO    KEEP   WELL 

through  them  into  the  peritoneal  cavity.  Some- 
times, even  when  early  operation  is  done,  infection 
has  already  taken  place  by  means  of  bacteria  which 
have  escaped  through  the  intestinal  wounds.  In 
a  large  percentage  of  cases,  however,  peritonitis 
and  other  forms  of  infection  are  prevented  and  the 
patient  is  saved. 

There  are  certain  chronic  ulcers  of  the  stomach 
and  intestines  which  tend  to  perforate  into  the 
peritoneum,  thus  causing  a  fatal  form  of  peritonitis. 
Of  232  operations  recently  reported  for  this  con- 
dition, 52  per  cent,  of  the  patients  were  saved. 
Perforated  typhoid  ulcers  have  thus  been  operated 
upon  successfully.  The  combination  of  typhoid, 
perforation,  and  operation  must,  however,  be 
so  grave  as  to  render  recovery  very  uncertain. 

Of  all  the  surgical  diseases  of  the  abdomen, 
appendicitis  has  attracted  the  most  popular 
attention.  Perityphlitis,  a  collection  of  pus  in 
the  right  side  at  the  head  of  the  large  bowel,  had 
long  been  known.  Its  danger  was  recognized,  and 
the  details  of  operation  were  well  established. 
What  was  not  known  was  that  abscess  in  this 
region  usually  results  from  inflammation  of  the 
vermiform  appendix,  and  also  many  cases  of  a 
very  fatal  form  of  peritonitis.  It  was  not  until 
1888  that  this  fact  was  fully  established  by  Fitz,  of 


MODERN    SURGERY  499 

Boston.  Post-mortem  examinations  in  patients 
dying  from  peritonitis  had  frequently  shown 
the  appendix  inflamed  or  filled  with  pus,  but 
this  was  supposed  to  have  been  secondary  to  the 
peritonitis.  There  was  nothing  to  indicate  that 
this  apparently  unimportant  little  organ  could  be 
the  source  of  so  much  trouble.  It  was  only  as 
surgeons  operated  earlier  and  earlier,  and  tracked 
the  inflammation  down  to  its  very  starting  point, 
that  the  truth  was  demonstrated.  The  appendix, 
it  may  be  said,  is  a  little  tube-like  body,  closed  at 
one  end  and  opening  at  the  other  into  the  large 
bowel.  It  is  simply  a  long,  narrow,  blind  pouch. 
Inflammation  of  the  appendix  is  probably 
always  the  result  of  germ  action.  Seeds  and  other 
foreign  bodies  are  found  in  about  one  case  in 
twenty,  but  it  is  doubtful,  even  when  they  are 
present,  whether  they  cause  the  inflammatiiDn.  The 
appendix  when  inflamed  readily  becomes  oc- 
cluded at  its  attachment  with  the  bowel,  fills 
with  pus,  and  ruptures.  This  usually  allows  the 
poisonous  pus  to  enter  the  peritoneal  cavity  and 
at  once  set  up  an  acute  peritonitis.  The  inflam- 
mation sometimes  extends  directly  to  the  peri- 
toneum without  any  rupture.  In  rarer  cases  the 
tissues  outside  the  peritoneum  become  involved, 
and  an  abscess  is  formed,  which,  as  it  increases  in 


500  HOW    TO    KEEP   WELL 

size,  may  at  any  moment  rupture  into  the  abdomen. 
If  the  abscess  is  promptly  opened  recovery  usually 
follows.  This  was  the  course  pursued  by  the 
disease  in  the  case  of  King  Edward.  His  case 
was  a  typical  one,  and  shows  what  every  surgeon 
knows,  that  serious  trouble  may  go  on  quietly 
for  some  days  without  giving  urgent  evidence  of 
its  presence.  No  skill  can  say  just  what  course 
the  disease  may  take  in  some  cases.  Sudden 
accidents  are  possible  even  when  everything  is 
apparently  going  well.  This  has  led  many  surgeons 
to  advise  operation  in  every  case,  notwithstanding 
the  fact  that  many  cases  recover  without  operation. 
This  is  no  doubt  extreme  ground,  but  the  medical 
man,  who  has  seen  patients  die  that  he  knows 
might  have  been  saved  by  prompt  operation,  may 
be  pardoned  if  he  shows  a  disinclination  to  take 
risks.  It  is  impossible  to  give  any  general  rules 
which  will  be  a  safe  guide  for  the  patient  himself 
in  deciding  this  momentous  question  of  operation. 
He  must  depend  upon  his  physicians,  who  will 
decide  the  question  after  taking  all  the  elements 
of  his  special  case  into  consideration.  If  delayed 
until  the  patient  is  exhausted,  or  a  vicious  form 
of  peritonitis  has  begun  even  slightly,  the  opera- 
tion may  be  unavailing.  It  is  then  the  disease, 
not    the    operation,    which    destroys   the    patient. 


MODERN    SURGERY  501 

When  there  have  been  several  attacks,  there  can 
be  no  question  whatever  as  to  the  advisability  of 
an  "interval  operation."  Setting  aside  the  pos- 
sibility of  a  fatal  result  of  some  future  attack,  the 
relief  of  mind  from  the  uncertainty  and  ever- 
present  dread  is  usually  worth  what  it  costs. 

Among  the  more  recent  aids  to  surgical  science 
are  local  anesthesia  and  the  Roentgen  ray.  The 
local  anesthetics,  cocaine  and  the  more  recent 
eucaine,  fill  wants  that  had  long  been  felt.  They 
are  particularly  useful  in  operations  upon  the  eye 
and  the  various  mucous  membranes,  by  which 
they  are  rapidly  absorbed.  Surgery  of  the  nasal 
passages  is  largely  done  by  their  aid.  They  do 
not  penetrate  the  skin,  and  therefore  must  be 
administered  by  hypodermic  injection  in  many 
localities.  The  rapid  absorption  of  cocaine,  thus 
taking  it  from  the  seat  of  operation  and  causing 
constitutional  effects,  is  the  chief  cause  of  limiting 
its  usefulness.  It  can  be  used  with  considerable 
freedom  upon  the  extremities,  as  they  can  be 
bound  by  ligatures  and  the  circulation  tempo- 
rarily stopped.  Very  recently  cocaine  has  been 
injected  into  the  lower  part  of  the  spinal  cord  with 
the  effect  of  causing  complete  anesthesia  of  the 
lower  portions  of  the  body.  Many  extensive 
operations  have  thus  been  performed.     The  exact 


502  HOW   TO    KEEP   WELL 

advantages  and  limitations  of  this  system  of 
"spinal  anesthesia"  have  not  yet,  however, 
been  fully  determined. 

The  discovery  of  the  Roentgen  ray  has  added 
greatly  to  the  exactness  of  surgical  diagnosis. 
The  nature  of  many  deformities,  the  location  of 
bullets,  foreign  bodies,  and  deep-seated  tumours, 
may  often  be  determined  with  great  certainty.  It 
is  now  employed  extensively,  and  its  use  is  increas- 
ing. In  many  conditions  its  use  requires  great 
skill,  and  the  interpretation  of  the  pictures  where 
numerous  organs  and  tissues  are  involved  demands 
large  experience.  They  may  prove  very  mis- 
leading to  the  inexperienced.  Improvements  in 
the  apparatus  are  constantly  being  made,  and 
skill  in  their  use  is  steadily  increasing.  It  was  a 
marvelous  discovery,  and  is  destined  to  be  an 
indispensable  aid  to  surgery.  As  a  curative  meas- 
ure in  cancerous  disease,  and  perhaps  in  tubercu- 
losis, there  is  much  evidence  at  hand  to  encourage 
hope.  Its  possibilities  in  these  directions  are 
being  tested  with  great  earnestness,  and  will  be 
largely  determined  in  the  near  future. 

Military  surgery  is  one  of  the  branches  of  general 
surgery  which  has  made  great  advancement. 
This  was  demonstrated  in  the  Sudan  campaign 
of    Lord    Kitchener,    in    which    the  medical  and 


MODERN    SURGERY  503 

surgical  preparations  were  probably  more  perfect 
than  in  any  other  expedition  in  liistory,  in  the 
Cuban  campaign,  in  South  Africa,  and  the  Philip- 
pines. In  these  recent  campaigns,  deaths  from 
wounds  have  been  extremely  small,  while  the  small 
number  of  amputations  and  major  operations 
would  have  amazed  the  surgeons  of  the  Civil 
War.  The  mortality  from  large-caliber  wounds 
during  the  Civil  War  was  53.7  per  cent.  That  of 
the  Santiago  campaign  was  8  per  cent.,  while  that 
from  small-caliber  arms,  which  were  unknown  in 
the  earlier  war,  was  virtually  nothing.  This  was 
partially  due  to  training  of  the  regular  troops  in 
proper  methods  of  caring  for  their  wounds  them- 
selves at  the  outset,  and  the  carrying  with  them 
of  "first-aid  packages."  These  packages  are 
simply  antiseptic  dressings,  which  are  to  be  applied 
at  the  earliest  possible  moment  after  receiving  a 
wound.  Everything  depends  upon  the  first  dress- 
ing and  subsequent  protection  of  the  wound. 
Battle  wounds  at  the  outset  are  usually  not  septic, 
but  become  so  by  subsequent  infection.  The 
tropical  heat  of  Cuba  in  July,  the  all-pervading 
moisture,  the  rank  vegetation,  and  lack  of  shelter 
from  the  elements,  combined  to  furnish  ample 
opportunities  for  infection,  with  the  resulting 
suppuration,  blood  poisoning,  and    gangrene.    All 


504  HOW   TO    KEEP    WELL 

these  were  surprisingly  rare.  Had  the  general 
official  management  been  as  efficient  as  the  immedi- 
ate surgical  treatment,  the  appalling  death  rate 
from  typhoid  and  yellow  fever  would  not  have 
occurred,  and  the  war  would  have  been  almost  as 
famous  for  its  small  mortality  in  the  army  as  it 
was  in  the  navy. 

The  remarkable  extension  of  railroads  has 
developed  a  new  department  of  surgery,  that 
known  as  railroad  surgery.  Each  important  road 
maintains  its  surgical  staff,  who  have  to  deal 
largely  with  peculiar  and  distinctive  types  of  injury. 
The  American  Society  of  Railway  Surgeons  is  a 
vigorous  organization,  which  has  added  much  to 
general  surgery  as  well  as  to  its  own  peculiar 
department. 

The  advances  made  in  surgery  during  the  past 
quarter  of  a  century  have  been  due  largely  to 
antiseptic  methods.  These  methods  were  the 
direct  result  of  the  acceptance  of  the  germ  theory 
as  the  causation  of  surgical  infection.  Progress 
was  more  prompt  and  decided  than  in  medicine 
because  the  conditions  were  more  simple  and  easy 
of  fulfilment.  The  surgeon  knows  that  infection 
is  liable  to  occur  at  a  certain  definite  time,  and  can 
prepare  beforehand  to  guard  against  it.  He 
knows,  moreover,  that  it  is  liable  to  occur  in  a  cer- 


MODERN    SURGERY  505 

tain  definite  place,  and  can  protect  that  place, 
even  though  it  be  vulnerable  for  a  long  period  of 
time.  The  physician,  on  the  other  hand,  does  not 
know  in  most  cases  when  infection  may  occur, 
nor  does  he  always  know  from  what  source  or 
by  what  channel  it  may  enter.  The  surgeon, 
being  forewarned,  can  be  forearmed,  and  can 
prevent  infection.  The  physician  is  informed 
only  after  infection  has  taken  place  and  the  bac- 
teria have  already  obtained  a  foothold  and  poisoned 
the  patient.  He  is  then  called,  not  to  prevent, 
but  to  counteract  the  results  of  infection  the  best 
he  may.  His  task  is  a  more  difficult  one  than  that 
presented  to  the  surgeon  when  he  is  called  early. 
The  problem  of  preventive  medicine  is  far  more 
intricate  and  difficult  than  is  the  problem  of  pre- 
ventive surgery.  It  was  necessary  for  the  phy- 
sician to  expend  vast  labour  in  studying  infectious 
germs,  learning  their  life  history,  the  sources  from 
which  they  are  derived,  the  channels  by  which 
they  enter  the  body,  and  the  way  in  which  they 
cause  disease.  For  ten  or  fifteen  years,  therefore, 
surgery  progressed  much  more  rapidly  than  did 
medicine.  During  the  past  ten  years,  however, 
the  more  decided  progress  has  been  made  by 
medicine.  During  the  decade  to  come,  it  may  be 
expected  that  this  progress  will  continue.     There 


5o6  HOW   TO    KEEP   WELL 

is  still  another  reason  for  greater  exactness  in 
surgical  practice  than  in  medicine.  The  surgeon 
carries  out  his  own  advice  and  it  is  done  skilfully 
and  correctly.  The  instructions  of  the  physician 
are  carried  out  by  others,  and  the  results  are  often 
spoiled  by  ignorance  or  carelessness.  "There 
would  be  more  successful  physicians,"  says  Quimby, 
"if  there  were  less  foolish  patients." 

While  improvement  in  surgical  practice  has 
resulted  from  steadily  accumulating  knowledge, 
as  well  as  from  increasing  personal  skill,  the  great 
advances  of  recent  years  have  been  due  in  chief 
measure  to  antiseptic  and  aseptic  methods — that 
is,  to  preventive  methods.  In  surgery,  as  in  medi- 
cine, therefore,  we  find  that  the  adage  is  as  true 
now  as  it  was  of  old,  that  prevention  is  better 
than  cure. 


INDEX 


Abscess,  184 
Accidents,  250 
Advanced  life,  469 
Aged,  Illness  of  the,  482 
Albumin  in  the  urine,  411 
Albuminoid  foods,  337 
Alcohol,     Effects    of,     257, 
373,  401,  410,  419,  426, 
428,  454,  473 
Alcohol  in  disease,  428 
Alcoholic   drink.   Consump- 
tion of,  246,  257 
Amusements     of     children, 

278 
Anatomy,  3 

Anesthesia,  General,  48 5 
Anesthesia,  Local,  501 
Anopheles  mosquitoes,   138 
Anthrax,     188 
Antisepsis,    45,    491 
Antiseptics,  45,  55,  56 
Antiseptic  solutions,  56,  58 
Antistreptococcic  serum, 

206 
Antitoxin,   41,  192 
Anxiety,    384 
Apoplexy,   416 
Appendicitis,    498 
Arteries,    Diseases    of,    414 
Artificial  foods  for  children, 

284 
Asepsis,  45,  56,  491 
Asiatic  cholera,    147 
Athletes,  417 
Authorities,    Medical,    21 
Autumnal  fever,  74 

Babyhood, 261 


Bacilli,  35 

Backward     children,      318, 

327 

Bacteria,  28,  492 

Bacteriology,  5,22 

Banting,  System  of,  436 

Bathing,  422,  433,  463 

Beer,  Use  of,  247 

Bichloride  solution,  56 

Bilious  attacks,  455 

Birth  rate,  253 

Black  death,  153 

Blood  poisoning,  36,  182 

Boils,  184 

Boiling  as  antiseptic  meas- 
ure, 59 

Boils,    184 

Boracic   acid,    59 

Boric  acid,  59 

Brain,  Development  of,  263 

Brain   localization,    496 

Bread,  349 

Breakdown,  357,  377,  381 

Bright's  disease,  245,  409 

Bronchitis,  185 

Broncho-pneumonia,   119 

Bubonic  plague,  153 

Cancer,   245,  440 
Carbolic  solution,  57 
Carbuncles,  184 
Casts,  411 
Catarrh,  311 
Cellular  pathology,   22 
Cereals,  352,  359 
Cerebro-spinal     meningitis, 

124 
Certified  milk,  290 


507 


5o8 


INDEX 


Chemistry,   4 
Chicken-pox,  105 
Child  Hfe,  Saving  of,  256 
Child  study,  274 
Children,  Diet  of,  282 
Children,  Nutrition  of,  295 
Children,  Rearing  of,  261 
Children,  Recreation  of,  275 
Children,  Summer  diseases 

of,  166 
Chloroform,    Discovery    of, 

490 
Cholera,   147 
Cirrhosis  of  the  liver,   246, 

426 
Cocci,  35 

Cod-liver  oil,  131 
Coffee,  360,  454 
Concentrated  foods,  354 
Condensed  milk,  285,  307 
Constipation,   446 
Consumption,  63 
Consumption,  Cures  for,  72 
Contagion,  43 

Contagious  diseases,  44,  54 
Contagious  period,  48 
Cooking,  Methods  of,  359 
Corpulence,  433 
Crisis,  47 

Croup,  True,  87,  201,  247 
Culex  mosquitoes,   138 

Death  rate,  253 
Degeneracy,  316 
Degeneration,  Arterial,  414 
Degeneration,    Fatty,    245, 

427.   453 
Dengue,  162 
Desquamation,  92 
Development,    Periods    of, 

324 
Diabetes,  431 
Diarrhea,    163,   246 
Diathesis,  310 
Diet    of    adults,    330,    398, 

458,472 
Diet  of  children,  282,  292 


Digestion,     Chemistry     of, 

336 
Digestion,  Feeble,   298 
Diphtheria,    80,    194,    240, 

430 
Diphtheria,    Pseudo-,    86 

Disease,  Causes  of,  18 
Disease,    Effect    of  modern 

life  upon,    241 
Diseases  common  to  various 

ages,  250 
Disinfectants,   57 
Disinfection,  58,  60 
Dissipation,  373,  382,  470 
Doctor,  The  modern,  2,  7 
Drinking  habits,   246,   247, 

257 
Dysentery,  175 

Dyspepsia,  188,  S3^ 

Education,  270 
Education,  Medical,  i 
Empyema,    123 
Endemic,  45 
Enteric  fever,  74 
Ephemeral    fever,    187 
Epidemic,  45 
Erysipelas,  179 
Ether,  Discovery  of,  487 
Exercise,  Physical,  454, 460, 

481 
Expectation   of  life,    258 

Facultative  germs,  36 
Fads,  391 

False  diphtheria,  86 
Family     physician,     Selec- 
tion of,  13 
Famine  fever,  190 
Farcy,  190 
Fatty     degeneration,     245, 

427,453 
Feeding  of  children,  284 

Ferments,  ^;^ 

Filth  diseases,  39,  153,  156 

Fluids,   Drinking  of,  355 

Foods,  Artificial,  286,  307 


INDEX 


509 


Foods,  Chemistry  of,  334 
Formaldehyde,  61 
Fourth  disease,  101 
Fractures,  494 
Fruits,    354 
Fumigation,  61 

Galen,    21 

Gall-stones,  427 

Galton,  Law  of,  316 

Gambling,  377 

Gardening,    482 

General    practitioner.    The, 

10,  13 
German  measles,  100 
Glanders,  189 
Glands,  Enlarged,  309 
Goiter,  496 
Gout,  347,  418,  421 
Grippe,  La,   no 
Gymnasium  work,  461 

Havana,  Malaria  in,  140 
Havana,    Yellow    fever   in, 

145 
Health  resorts,  425 

Heart,  Disease  of,  131,  429 

Heating  of  rooms,  466 

Heredity,  38,  264,  314 

High  pressure,  371,  381,  383 

Hip  disease,  63 

Hippocrates,  18 

Histology,  4 

Hydrophobia,  163,  208 

Hysteria,  276 

Immigration,  242,  253 
Immunity    to    disease,    39, 

193 
Immunizing    by    antitoxin, 

200 
Impersonal  diseases,  403 
Incubation  period,   46,   48, 

49 
Indigestion,  188,  338 
Infancy,  262 
Infant   feeding,    Books   on, 

294 


Infection,  43,  504 
Infectious  diseases,  43,  63 
Influenza,  no 
Intermittent  fever,  132 
Intubation,  201 
Isolation  in  infectious  dis- 
eases, 49,  54 

Jenner,  217 

Kidney   disease,  245,  409 
King's  evil,   310 
Klebs-Loffler  bacillus.  Si 
Koch,  25,  31,  149 

Laxatives,  449 

Leprosy,  160 

Leucomaines,  ^'] 

Lister,  Lord,  491 

Lithemia,  421 

Liver,  Disease  of,  246,  426, 

453 
Lobar  pneumonia,  114 

Lockjaw,  177 

Lunches   of   business   men, 

398 

Malarial  fever,  132,  247 
Malnutrition     of     children, 

29s 
Malthus,  Doctrine  of,  255 
Marasmus,  300 
Materia  medica,  5 
Measles,  95,  10 1 
Meat  eating,  346,  454 
Medical  education,  i 
Membranous  croup,  ^"j 
Meningitis,  124,  497 
Miasmatic  disease,  44 
Micrococci,  35 
Middle     life.    Diseases      of, 

364,  403 
Middle      life,      Physical 

changes  of,  378 
Military  surgery,  502 
Milk,  287,289,355 
Mixed  infection,  86,  90 
Moderate  drinking,  402 


Sio 


INDEX 


Modern  medicine,  i,  7 

Modified  milk,  287 

Mortality  at  various  ages, 
249 

Mortality,   Infant,   257 

Morton's  demonstration  of 
anesthesia,  487 

Mosquitoes  as  disease  pro- 
ducers, 138 

Mothers,  272 

Mouth,  Diseases  of,  187 

Mumps,    106 

Muscular  development,  461 

Myocarditis,  245 

Nephritis,  409 
Nervous  children,  275,  325 
Nervous  disorders,  325 
Nervous    prostration,    276, 

377.397 
Neurasthenia,  276,  377,  397 

New  business  in  later  life. 

Noise,    Unnecessary,   466 
Nurses,  Trained,  7 
Nursing,  Maternal,  282 
Nutrition  of  children,  295 

Obesity,  432,  433,  456 
Occupation,  Importance  of, 

475.479 
O'Dwyer,   Doctor,   201 

Old  age,  467 
Ovariotomy,  494 
Overcrowding     of     popula- 
tion,  243,  372,  381 
Overeating,  452 

Pandemic,  46 
Parasites,    35 
Parotitis,  106 
Pasteur,  23 
Pasteurized  milk,  289 
Pathology,  5 
Peritonitis,  496 
Perityphlitis,  498 
Personal  diseases,  403 


Pertussis,  107 
Pharyngitis,  186 
Phrenology,  496 
Phthisis,  63 
Physician,  Family,  13 
Physiology,  3 
Plague,  153,  207 
Plasmodium    malarias,    42, 

132, 134 

Pleurisy,  122,  497 

Pneumonia,  114,  207 

Population,  Increase  in,  252 

Population,  Overcrowding 
of,  243,  372,  381 

Post-graduate  study,  6 

Potatoes,  253 

Pott's  disease,  63 

Practitioner,  The  general, 
10,  13 

Precocity,  268 

Predisposing  causes  of  dis- 
ease, 38 

Ptomaines,  34 

Pus  formation,  180 

Putrefaction,  t^t, 

Quarantine  period,  48,  49 
Queer  people,  389 
Quick  lunch,  244,  398 
Quotidian  fever,  132 

Rabies,   163 
Rachitis,  285,  300 
Railway  surgery,  504 
Recreation,  374 
Regimen  of  adult  life,  330 
Relapsing  fever,  191 
Remittent  fever,  136 
Resigning  official  positions, 

479 
Responsibility,  367,  381 
Retiring  from  business,  477 
Rheumatism,  127,  421,  430 
Rice,  351 
Rickets,  285,  300 
Rontgen  ray,  73,  445,  501 
Rotheln,  100 


INDEX 


5" 


Rubella,  loo 
Rubeola,  95 
Ruts,  387 

St.  Virus's  dance,  128 
Sanitoria  for  consumptives, 

71 

Saprophytes,  35 
Scarlatina,  89 
Scarlet  fever,  89 
Schools,  Medical  inspection 

of,  50 
Schools  of  medicine,  13 
Scrobutus,  306 
Scrofula,  63,  99,  308 
Scurvy,  306 
Sedentary  life,  373,  451 
Senile  pneumonia,  121 
Septic  disease,  45,  180 
Septicemia,   36 
Sexes,  Vitality  of,  248 
Sick-room,  52 
Sleep,  Importance  of,  398 
Smallpox,  102,  210 
Sore  throat,  186 
Specialism,  8,  386,  391 
Specialist,   Selection  of,    12 
SpirilH,  35 

Spontaneous  generation,  38 
Spores,  30 
Sputa  flasks,  69 
Staphylococci,  35,  181,  186 
Start  the  diet  right,  292 
Stegomyia  mosquitoes,  145 
Sterilized  milk,  289 
Stimulants,     Reliance     on, 

374 
Stomach,  Ulcers  of,  498 
Stomatitis,  187 
Stoutness,  433 
Strasburg  goose,  452 
Straus  milk  depots,  291 
Strenuous  life,  366,  380 
Streptococci,   35,    181,    179, 

186 
Struma,  308 
Sugar,  357,432 
Suicide,  251 


Sulphur  fumigating,  61 
Summer  diarrheas,  166 
Sure  cures,  406 
Surgery,  modern,  484 

Tea,  360 

Tension  of  living,  371,  381 
Terminal  diseases,  116 
Tertian  fever,  132 
Tetanus,  177,  208 
Therapeutics,  5 
Thompson,  Sir  Henry,  471 
Tobacco  heart,  401 
Tobacco,  Use  of,  373,  399 
Tonsillitis,  128,  186 
Toxins,  34,  192 
Toys  for  children,  280 
Transmissible  diseases,  44 
Tuberculin,  73,  209 
Tuberculosis,  63,  254,  209, 

309 
Tumours,  443 

Typhoid  fever,  74,  246,  498 
Typhus  fever,  158,  207 

Uric  acid  condition,  421 

Vacations,  393 
Vaccination,  210 
Valvular  disease,  429 
Varicella,  105 
Variola,  102 
Vegetables,  353 
Vegetarianism,   335 
Ventilation,  466 
Virchow,  22 
Vitality  of  the  sexes,  248 

Walking,  462,  482 
Water,  Use  of,  354,  356 
Watering  places,  425 
Whooping-cough,  107 
Widal's  reaction,  79 
Women  who  need  rest,  396 
Worry,  384 
Wounds,  Care  of,  184 
Wrong  living,  373 

Yellow  fever,  144 


^ 


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